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ABDOMINAL PAIN

PROF. DR. NORBERT ORTNER

CHIEF OF THE SECOND MEDICAL CLINIC AT THE UNIVERSITY

OF VIENNA

AUTHORIZED TRANSLATION BT

WILLIAM A. BRAMS, M.D.

FORMERLY LIEUTENANT-COMMANDER, MEDICAL CORPS, U. 8. N.

AND

DR. ALFRED P. LUGER

FIRST ASSI8TANT, SECOND MEDICAL CLINIC,
UNIVERSITY OF VIENNA

MK1MCAL ART A(iKN(Y

(KOKMK1U.Y UK1IMAN COMPANY)

NEW YORK
SO IRVING PLACE (COR. «• 16tm 9T )
TEL CALEDONIA 3012

ABDOMINAL PAIN

Translator*! Preface

The translation of this volume on abdominal
pain was undertaken with the desire to present
the teachings of the school of Bamberger, Neus-
ser, and Ortner in what is perhaps their best and
most adequate form. The work is based upon the
wide personal experience of one of the principal
figures in the school it represents, and most of
the diagnoses it contains have been carefully veri-
fied by surgical and anatomical procedures. The
translators hope that it will fill the need for a
concise and competent discussion of the subject
as seen by the clinician in his daily work.

Professor Ortner has kindly consented to some
slight modification in the style and to some slight
condensation in order to make the material more
accessible to the English and American reader.

The translation is of the second and latest
edition of the work.

Translator's Preface ix

Introduction xiii

Diffuse Abdominal Pain 1

Intense, Diffuse Abdominal Pain with Shock.. 1
Severe, Diffuse Abdominal Pain with Shock and

Ileus 3

Pain, with Shock but without Ileus 45

Severe, Diffuse Abdominal Pain, without

Shock 54

Mild, Diffuse, Colicky Pain 78

Mild, Diffuse, Abdominal Pain not Colicky in

Nature 79

Localized Abdominal Pain 83

Epioastraloia or Stomach Cramps 85

Colicky Epigastralgia 85

Acute Continuous Epigastralgia 141

Acute, Epigastric Pains of Shock Duration

Which are not Cramp-like in Nature 149

Chronic Continuous Epigastralgia 155

Pain in the Right Hypochondrium 163

Colicky Pains in the Region of the Gallbladder

and Right Hypochondrium 163

Acute Continuous Pain in the Right Hypo-
chondrium Over the Gallbladder Region 192

Chronic Continuous Hypochondrialgia Dextra

in the Gallbladder Region 197

Diffuse Pain Over the Right Hypochondrium. 198

xii CONTENTS

Pain in the Right Ileocecal Region 203

Colicky Pains in the Ileocecal Region 203

Acute Continuous Pain in the Ileocecal Region 211

Recurrent Pains in the Ileocecal Region 240

Chronic Continuous Pain in the Ileocecal Re-
gion 247

Acute Pains in the Left Iliac Region 250

Recurrent Pains in the Left Iliac Region. . . . 256
Constant Sensation of Discomfort in the Left
Iliac Region 258

Pains in the Lumbar Region, Flanks, and Lat-
eral Parts of the Abdomen 260

Lumbar Pains 260

Acute Continuous Pain in the Lumbar Region. 275

Chronic Recurrent Lumbar Pain 287

Chronic Continuous Lumbar Pain 290

Pain in the Planks 297

Chronic Continuous Pain in the Flanks 303

Lumbar Pain in the Middle Line 304

Pain in the Left Hypochondrium 306

Bilateral Hypochondbial Pain 315

Pain in the Region of the Navel 317

Pain in the Hypogastric Region 328

Appendix 337

Radiating Abdominal Pain 337

Relation of Abdominal Pain to the Intake of

Pood 338

Abdominal Pain During Defecation 339

Abdominal Pain Associated with Bodily Motion 340
Abdominal Pain Associated with a Sensation of

Anxiety 341

Abdominal Pain Associated with Obstipation . . 341
Abdominal Pain Associated with Menstruation . 341

Index 343

Introduction

We include in this large chapter all those
diseases in which the particular complaint of
the patient is pain in the abdomen. Posttrau-
matic affections, such as those following an
accidental rupture of the spleen, etc., are not
considered in this connection. Fortunately, we
are seldom called upon to make a diagnosis
on the consideration of the pain alone. There
soon develop other and objective findings which
aid us; but the pain often points out the di-
rection we must follow in the objective exami-
nation in order to arrive at the proper diag-
nosis. It is one of the early symptoms and
serves as a guide through the maze of possibili-
ties, and, therefore, it seems justifiable to me
to consider the pain as the starting point in the
differential diagnosis.

ABDOMINAL PAIN

Diffuse Abdominal Pain

Intense, Diffuse, Abdominal Pain With Shock

Our first considerations in the presence of very
severe and sudden abdominal pain of such a great
intensity or overwhelming severity that the pa-
tients almost lose consciousness or believe that
death is imminent are: acute intestinal obstruc-
tion, acute perforation of a diseased organ
(stomach, intestine, bladder, ureter, Fallopian
tube, uterus, gallbladder) and the rupture of an
abscess into the free peritoneal cavity from the
appendix, cecal region, liver, spleen, pancreas,
etc.

Next in order is torsion of a pedicled organ
as a cystic ovary, omentum, gallbladder.
Fallopian tube, floating kidney, wandering spleen
or cyst of the mesentery. We must also consider
torsion, contusion or fulminating inflammation
of the testicle, extra-uterine pregnancy, acute
strangulation of hemorrhoids, and pus or inflam-
mation in the groin or abdominal muscles.

Another class of causes consists of severe renal
colic, less often gallstone colic, pancreatic inflam-

etc.

Ni
such

2 ABDOMINAL PAIN

mation, necrosis or hemorrhage of this organ,
severe lead colic, acute deficiency of the adrenals
as in Addison's disease, and tabetic or vascular
crises in the abdomen.

The list of possibilities ends with a considera-
tion of extraabdominal conditions, such as sub-
diaphragmatic angina pectoris or hysteria.

Another symptom, ileus, may accompany the
intense initial pain in the aforementioned dis-
eases, except in the rupture of an organ, subdia-
phragmatic angina pectoris, and acute adrenal
insufficiency. In speaking of ileus in this connec-
tion, I do not mean that one must wait for fecal
vomiting. Although this is a cardinal sign, it is
not an early one. I do wish to emphasize the im-
portance of the early symptom complex of com-
plete obstruction of the bowel as betrayed by in-
ability to pass feces or flatus per rectum.

To be sure, this symptom of ileus cannot bear
too much weight during the first few hours of the
illness, as it may be present in conditions other
than those mentioned here or it may clear up very
soon and not be a result of obstruction of the
bowel. We may say that ileus is present when
the passage of flatus is uninterruptedly absent
for some hours, at least twelve, and during which
time, of course, no feces are passed.

The following discussion will be based on the
question: what diseases are to be considered
when the patient complains of a sudden anni-

ABDOMINAL PAIN WITH SHOCK AND ILEUS 3

hilating pain in the abdomen, with no passage
of feces or flatus for several hours, with re-
peated vomiting accompanying the initial pain,
the vomitus containing urobilin with many co-
lon bacilli and, subsequently, fecal vomiting in
the later course of the disease ? The presence of
urobilin and many colon bacilli in the vomitus
of early ileus is an important but not character-
istic finding of this condition.

:re, Diffuse Abdominal Pain, with Shock
and Ileus

Acute intestinal obstruction in all its forms
serves first mention, but not all these cases
show the intense degree of pain which is under
discussion. It is present only in those cases in
which the obstruction of the lumen is accom-
panied by a strangulation of the mesentery, with
a resulting pulling or tearing of the mesenteric
nerves and interruption of the circulation. This
occurs in complete torsion or noose formation of
the bowels, intraabdominal incarceration, occa-
sionally in simple bowel occlusion resulting from
kinking at a site of adhesions, and in some cases
of intussusception.

The overwhelming character of the pain is,
however, absent in simple cases of obturation,
as by gallstones, foreign bodies, intestinal para-
sites, or fecal masses. In a like manner, the ex-
treme degree of pain may also be absent in some

•I I - ■ ' I

The before-asentioDed type of
seen in the eases of acute obstruction which
arear as the molt of a previously existing ehranie
d bs tmcti on of the boweL Cases in which there is
• fcwp t ^fy of the " K ^f'^' j or sn
tioo bjr peritoneal adhesions may, however,

very ttvtrt pom*

As previously mentioned, strangulation is
characterized by the intense degree of pain which
it produces. Generally speaking; the intensity of
the pain is much more marked in obstruction
with strangulation of the small bowel than with
that of the colon* The severest pain is observed
in cases of internal incarceration. Torsions,
which occur chiefly in the large intestine, are not
characterized by such very severe and overwhelm-
ing pains* Invagination of the large bowel, on
the other hand, produces pains of almost the same
intensity as those produced by obstruction of the
small intestine. The pain in strangulation is con-
tinuous as a rule, with many remissions and ex*
acerbationt. This feature is absent, however,
in the very acute and rapidly fatal cases of in*
testinal obstruction. Complete intermission of
the pain is very much more rare and occurs only
in cases where the invagination or torsion was

INTERMITTENT COLIC — STRANGULATION

incomplete and the process has partly returned
to the normal state. This latter type of intermit-
tent colic is caused by the strangulation and
stronger peristaltic contractions. The longer the
crampy pains continue, the more severe they be-
come, except in those cases which are com-
plicated by peritonitis and collapse, where the
pain may even disappear entirely. The pain in
strangulation consists of two components, one
which is continuous and another which consists
of a wave-like increase followed by a decrease
of the pain. This latter wave-like pain lasts but
a few minutes but is repeated many times.

The pain in strangulation, is not, as a rule,
always definitely localized, and a circumscribed
area of tenderness is also often absent. This ab-
sence of distinct localization is of very great
diagnostic value in differentiating strangulation
from renal or gallbladder colic, or from pancrea-
tic pains. The most striking feature of a stran-
gulation pain is its general effect on the body in
producing collapse, anxiety, acceleration of the
pulse rate after the initial bradycardia is gone,
the incomplete filling of the peripheral vessels,
pinched facies, hollow voice, cold extremities,
cold sweats, and, occasionally, a subicteric tinge.
All these are absent in pure occlusion.

The characteristic criteria of intestinal ob-
struction in general will now be discussed. The
most important signs are inability to pass feces

6 ABDOMINAL PAINI

or flatus and the presence of a high, metallii
sound on percussion or auscultation of the intes-
tines. In addition, there is the initial reflex
vomiting which is followed by an intermission of
several hours and then by fecal vomiting; finally,
there is albuminuria and anuria. Fecal vomiting
may not appear at all in those cases of very
acute strangulation ileus which are attended by
an early fatal ending. Visible peristalsis or
stiffening may also be absent. A strand of
strongly contracted bowel may sometimes be
palpated at the site of the strangulation in the
early stages. In other cases, we may see the
peristaltic movements of the segments of bowel,
proximal to the obstruction, even in the early
stages. These peristaltic waves are characterized
by the fact that they all stop at a fixed point and
do not produce a gurgling sound, a finding which
means that the peristaltic contraction is not
strong enough to force the contents through the
obstruction.

We sometimes find a local meteorism of the
strangulated, fixed, and motionless loop of in-
testine, a sign described by Wahl-Schlange't
sign may be present and is produced by percus-
sing the segment of bowel above the obstruction,
whereupon this distended loop shows visible or
palpable peristaltic contractions. Both these
signs may be absent if there is diffuse meteorism
above the site of obstruction or when the ob-

struction is located in an inaccessible place, such
as deep in the abdomen, along the spine, or in the
pelvis.

Another sign which is often present but dif-
ficult to demonstrate, is the early appearance
of fluid, as shown by dullness in the flanks. This
fluid resembles that found in a hernial sac, or it
may even be hemorrhagic. Finally, there is a
disappearance of the liver dullness in the pres-
ence of a high grade meteorism with tension of
the abdominal walls, a finding which is not seen
in the early stages of obstruction ileus.

It is difficult to differentiate the several va-
rieties of obstruction in which there is also stran-
gulation. This is especially true in the differ-
entiation of volvulus from incarceration. It is
easy to distinguish between them if the latter is
an externa] incarceration, even if the symptoms
continue after apparent reduction of the incar-
ceration. The differentiation is more difficult, if
not impossible, between an internal incarcera-
tion and a kinking of the bowel with strangu-
lation. In general, it may be said that an in-
ternal incarceration is the more probable if
there is a history of previously existing peri-
toneal adhesions. The location may also give
us a hint of the underlying cause, as we know
that internal incarceration occurs almost always
in the ileum, very rarely in the jejunum, or
colon, and never in the duodenum or rectum.

8 ABDOMINAL PAIN!

In strangulation of the large bowel, the great-
est possibility is volvulus. Incarceration of this
part is rare, while torsion of the sigmoid flexure
is more common at this place than in the small
intestine.

When two different portions of the bowel are
simultaneously involved in a knot formation, the
most frequent combination is ileum and sigmoid,
rarely between two loops of small intestine, and
only exceptionally between a loop of the small
intestine and cecum or colon ascendens.

Strangulation of the sigmoid flexure is char-
acterized by massive distention of the lower part
of the left abdomen, with a high tympanitic or
even metallic percussion note over this region.
It is also characteristic of this condition that the
distention becomes very great in a short time,
reaching over to the upper right quadrant, and
filling the entire abdomen in two or three days.
It may be very difficult to determine whether
this diffuse and extensive meteorism in the late
stage is due to simple distention or peritonitic
meteorism. Another sign which points to stran-
gulation of the sigmoid is tenesmus, especially
when accompanied by early vomiting which is not
fecal. Both these signs may be explained by the
low site of the obstruction.

Volvulus of the sigmoid flexure occurs, gen-
erally, in people of about 50 years of age. The
course is comparatively mild in spite of the high

degree of meteorism; the initial collapse is not
very marked, and the symptom complex of ileus
is not complete, as there is, occasionally passage
of flatus. It often occurs after a dietetic error,
such as after eating food which causes extreme
distention. In rare cases we may observe bloody
stools without fecal contents, a finding explained
by the fact that the lesion is very low and that
hence there are no feces in the distal part of the
intestine. These bloody stools speak against
incarceration.

Volvulus of a congenitally large sigmoid is
characterized by the appearance of meteorism, at
first in the center of the abdomen, and later in
those places where the loops, which are at first
located in the midline, eventually happen to shift.
Subsequently, the tympanites extend to the right
and to the upper left quadrant, pushing the small
intestines into the left lower quarter, a position
which is the contrary to that of the normal state.

Volvulus of the small intestine is characterized
by the contrast between the degree of vomiting
and of the meteorism. In volvulus of the large
bowel, the meteorism predominates, while in
this affection of the small intestine, the vomiting
is profuse, and the meteorism is rather moderate,
providing that there is no complicating peri-
tonitis. Meteorism may even be absent in vol-
vulus of the small bowel if the course is rapidly
fatal. The meteorism is located chiefly in the

10 ABDOMINAL PAIN

middle and upper part of the abdomen, and there
is absence of tenesmus or bloody stools, as de-
scribed under volvulus of the sigmoid. Further-
more, the vomiting and the entire course is very
stormy in volvulus of the small intestine, while
the vomiting in case of volvulus of the sigmoid is
comparatively mild. It may furthermore be
mentioned that a short period of relief following
the vomiting speaks for involvement of the sig-
moid and rather against volvulus or incarceration
of the small bowel.

It is very difficult or even impossible to dis-
tinguish between volvulus and incarceration of
the small intestine. Generally speaking, inter-
nal incarceration of the small bowel, especially of
the ileum, is more frequent than volvulus of this
region. Passage of gas or feces several days
after the onset of the acute obstruction speaks
rather for volvulus of this portion of the bowel
than for incarceration. In incarceration, there
is, on the contrary, immediate cessation of pas-
sage of gas or feces, due perhaps, to a reflex
paralysis of the intestine. Pain which is limited
to the back, or which is more severe in this region
than in the anterior surface, speaks for volvulus
of the small bowel. This pain may perhaps be
explained by a pulling or tearing of the mesen-
tery at its attachment near the spine. The pains
in eases of internal incarceration, when they are
at all localized, are found chiefly in the umbilical

INCAECEEATION — INTUSSUSCEPTION

region, as this place corresponds in a general
way to the location of the small intestine. The
pain is rarely limited to other regions, as to the
site of the incarceration. The pain may even be
found in a region not at all corresponding to the
site of the obstruction.

I wish to emphasize the point that bloody stools
are practically never seen in internal incarcera-
tion and have no connection with this type of ob-
struction of the small bowel. It is, however, just
this appearance of bloody stools which can be of
great use to us in the differentiation between
acute intussusception with signs of strangulation
and the various other types of intestinal obstruc-
tion with strangulation. Bloody stools are prac-
tically always absent in cases of incarceration,
are rare in cases of volvulus or obstruction by a
foreign body, but are present in about eighty
per cent, of cases of intussusception. The reason
for the presence of blood, or blood and mucus,
in the stools of the latter condition is that the
exposed mucosa of the invaginated portion and
of the outer covering segment of bowel continue
to shed blood and mucus. This apparent passage
of blood and mucus may continue even if nothing
passes the actual site of obstruction. On the
other hand, there is no such bleeding mucosa
distal to the site of obstruction in incarceration,
and, furthermore, the actual obstruction is usually
complete.

ABDOMINAL PAIN

The ileocecal region is the most frequent site
for intussusception in children, while invagina-
tion of the small bowel above this location is
more rare. In adults, both regions are involved
with the same frequency and are usually caused
by benign tumors, such as polyps. Intussuscep-
tion of the colon is much less frequent. It is also
evident that tenesmus is not uncommon in acute
intussusception because of its low location at
the cecum. Tenesmus is, however, nearly always
absent in invagination of the small bowel. Vomit-
ing does not often occur in these conditions and
the meteorism is, as a rule, moderate. The chief
diagnostic feature in intussusception is, however,
the finding of a palpable tumor, the consistency
of which may be felt to change during its inter-
mittent contractions. One finds a tense, elastic,
sausage-shaped tumor which may disappear in
a few moments when the pains and contractions
diminish. The tumor may occasionally remain
permanently and is usually to be found in the
region of the cecum or sigmoid, or in the rectum.
Another sign which is of value is cyanosis of the
anal region. This sign does not occur in carcino-
ma of the rectum or in dysentery, two conditions
which may be confused with intussusception.

Another condition which has to be considered
is a combination such as the appearance of an
acute internal incarceration in the course of a
previously existing, chronic obstruction of the

CHBOXIC OBSTBtTCTION 13

large bowel. The diagnosis may be made by con-
sidering the sequence, that is, the appearance of
symptoms of an acute obstruction in the presence
of a chronic obstruction. If the chronic obstruc-
tion is in the large bowel and the acute disease
in the small intestine, there will then be a shift-
ing of the meteorism from the flanks to the new
location around the umbilicus. The change in
the location of the pain may also prove of value
in the diagnosis.

Acute obstruction may show relapses or repe-
titions, but these must not be confused with the
exacerbations of a chronic obstruction. Recur-
rent attacks of acute obstructions often cause
repeated attacks of colic lasting twelve to twenty-
four hours and recurring at intervals of two
to three days. The picture of obstruction is of-
ten incomplete. The appearance of bloody, or
bloody and mucous, stools speaks for subacute
intermittent intussusception. The underlying
cause for acute, intermittent, that is, repeated
obstruction with complete ileus, may be a recur-
rent volvulus of the sigmoid or recurrent inter-
nal incarceration following a previously sponta-
neous reduction. The case may be true of a
recurrence after spontaneous return to normal
of a kinking, torsion, or neoplasm of the in-
testine.

Furthermore, we must consider a spontaneous-
ly healed intussusception which is followed by a

ABDOMINAL PAIN

circular scar and which later produces an acute
or chronic stenosis. Another cause of intermit-
tent stenosis may be the presence of a movable
tumor, such as a mesenteric cyst, which may
periodically compress the bowel or cause torsion.

We must think of the possibility of foreign
bodies occluding the bowel, such as gallstones,
a clump of ascares, or a fecolith, when complete
relief follows attacks of ileus, and when these
attacks recur at intervals of weeks or months.

A perforation of one of the abdominal organs,
rupture of a hydronephrosis, the so-called apo-
plexy into the perirenal tissues, or the bursting
of an abscess into the free peritoneal cavity will
produce severe, overwhelming pains in the abdo-
men, with shock. The pains and shock will be as
severe as in strangulation. If an abscess rup-
tures into a previously walled-off space, the pains
will be less severe, and the general effect on the
nervous system will be much less marked. It is
the initial shock which characterizes perforation
into the free peritoneal cavity. The appearance
of perforative peritonitis which occurs in from
four to twelve hours may change the picture to
one of paralytic ileus, and this condition may
closely resemble a strangulation ileus.

The diagnosis of a perforation ileus is difficult
only when there is no history of a previously
existing cause, such as peptic ulcer, etc. The
diagnosis of a perforation may be made on a bis-

PEBFOBATION ILEUS

tory of an acute, severe pain, persisting for one
or more hours, and the presence of a board-like
rigidity of the abdominal muscles, two phenomena
not often seen in strangulation unless we are deal-
ing with an acute intussusception. The intense
shock may occasionally lead to absence of mus-
cular rigidity and may even produce a flabbiness
of the abdominal walls. We must also remem-
ber that the degree of muscular rigidity de-
pends in great part upon the inherent muscular
power, being less in multipara or in patients with
ascites or certain nervous diseases. Further-
more, it has been especially observed that muscu-
lar rigidity is absent in perforation of a pyloric
carcinoma. The degree of pain may also vary in
the same way and under the same conditions that
cause the variable degrees of rigidity.

Early, generalized tenderness, especially if
elicited by very light percussion, speaks for per-
foration peritonitis and against strangulation.
Tenderness is also much less marked in the latter
condition, or may even be absent, only two types
of strangulation may be accompanied by moder-
ate tenderness, these being internal incarceration
of a few days' duration or torsion followed by
rapidly developing meteorism.

Local meteorism or an asymmetrically dis-
tended abdomen with bulging in circumscribed
areas speaks for strangulation. The meteorism
i perforation peritonitis is, however, symmetri-

ABDOMIXAL PAIN

cal. Further differential points in favor of
strangulation are the presence of the previously
mentioned Wakl's and Schlange's signs.

Just as the patient with peritonitis presents
diffuse ahdominal tenderness, so will he also com-
plain of continuous or nearly continuous pain.
On the other hand, the pain in acute intestinal
obstruction is periodic with intervals of relief. We
must not be misled, however, by the period of
relief which separates the initial pain of the per-
foration from the subsequent pain of the resulting
secondary peritonitis. This is especially likely
when the perforation occurs into a previously
walled-off space, and it may occasionally occur
also, in perforation into the free peritoneal
cavity. The peritonitis patient remains perfect-
ly quiet, he avoids all changes of position, keeps
his lower limbs drawn up and motionless, and
avoids any movement of the diaphragm, such as
coughing or deep breathing. The patient with
strangulation is not so careful, a change in posi-
tion does not increase the pain. Coughing and
sneezing may increase the pain in strangulation,
but even then abdominal breathing is possible as
long as there is no extensive meteorism.

Another diagnostic sign of perforation peri-
tonitis or other types of peritonitis is the absolute
quiet in the abdomen on palpation or ausculta-
tion, with no sign of peristaltic movements. On
the other hand, cases of strangulation do show

peristaltic movements, but I should like to add
that, according to my experience, weak peristal-
tic movements may be heard and palpated even
in case of diffuse purulent peritonitis with or
without perforation ; even after several days have
passed it is evident, therefore, that only the nega-
tive finding is decisive, while the positive finding
is unreliable.

Fever of mild or considerable degree during
the first few hours after the onset of the pain
with vomiting, speaks rather for peritonitis; but
fever later in the course bears no such differen-
tial value, as peritonitis sets in very early and
very easily in strangulation. Determination of
the axillary and rectal temperatures at the same
time may greatly aid us in these cases. If the
rectal temperature is two degrees or more higher
than the axillary, it is an almost certain sign of
peritonitis. Absence of this difference, or the
presence of a subnormal temperature, is a finding
of no value from a negative point of view and
may be seen at any stage, even in cases of peri-
tonitis.

Furthermore, severe, continuous vomiting
speaks for peritonitis, while there is, usually, a
period of rest between the initial vomiting in ileus
and the subsequent emesis. This must not be
considered as characteristic, because there are
some cases of peritonitis in which such a pause is
present and may extend over a number of days.

ABDOMINAL PAIN

., and

Ischuria, difficult and painful urination,
painful strangury speak rather for peritonitis
than for acute obstruction of the bowel, but these
signs are not characteristic for either peritonitis
or obstruction when they occur in the pelvis, as
both conditions in this region may produce uri-
nary symptoms.

Pneumoperitonitis occurs when air enters the
peritoneal cavity. Its recognition is, however,
easy only when large quantities of air enter
rapidly. In these cases we find a tympanitic per-
cussion note which is of the same quality all over
this area. Auscidtation also reveals the absence
of any sound such as intestinal gurgles or splash-
ing over a large area. Both these findings are
especially to be seen over the anterior and lateral
surfaces of the fiver, and the absence of intestinal
sounds is best determined by listening over the
axillary surface of the liver while the patient is
on his left side. When but a small quantity of
air escapes into the free peritoneal cavity, it tends
to collect over the median portion of the liver
and may be distinctly different in note from the
surrounding tympany of the stomach and intes-
tines. We must be very careful, however, not to
confuse this circumscribed collection of air in
perforation with the localized meteorism some-
times seen in obstruction. This applies especial-
ly in cases where the colon lies in an unusual loca-
tion as, for instance, in the case of a congemtally

PERITONITIS — 3IETEORISM

long colon which may lie in front of the liver.
We must keep in mind that the air bubble in the
free peritoneal cavity will seek the highest level
and we must, therefore, turn the patient on his
left side in order to look for this air bubble on the
axillary surface of the liver; a sign which is not
found in intestinal tympanites. We must also
bear in mind the possibility that this air bubble
will not shift its location if there are adhesions
between the liver and the abdominal wall.
Traube's sign may also, according to my experi-
ence, be relied upon; it consists of finding a
doughy consistency in the epigastrium in cases of
pneumoperitoneum. According to my observa-
tion, in cases where the perforation is closed, the
distended epigastrium goes down after a few
days, while the surrounding parts still remain
distended.

The general, paralytic meteorism which occurs
in acute, and especially in subacute, peritonitis is
characterized by the previously mentioned ab-
sence of appreciable intestinal sounds or of per-
istalsis or stiffening, and the entire abdomen
shows a diffuse, high grade distention. The dia-
phragm is pushed upward as high as possible, so
that the borders of the area of cardiac dullness
are completely gone, and the area of pulmonary
resonance is somewhat diminished, phenomena
which are only really found in this form of in-
testinal obstruction.

ABDOMINAL PAIN

The diagnosis of acute peritonitis may, fur-
thermore, be made on the demonstration of i
exudate. A fibrinous exudate may manifest it-
self by a friction rub over the liver or spleen,
while dullness in the flanks speaks for a flu;
exudate. Of course, we can hardly expect to f
these signs in the early stages of perforation I
fore a demonstrable peritonitis has set in. How-
ever, even if a fluid exudate already exists, we
may not be able to make use of it for diagnostic
purposes if the tension of the muscles in the early
stages, or the meteorism in the later stages in-
terfere with the manifestation of dullness in 1
flanks. Furthermore, flank dullness occurs i
in cases of pancreatic necrosis, some cases of acute
strangulation ileus, internal incarceration, and
especially in volvulus where venous stasis of the
twisted mesentery occurs. In addition, we may
find flank dullness in cases of intestinal obstruc-
tion in which the loops of bowel themselves con-
tain fluid and air. In these cases, the fluid will
tend to gravitate to the most dependent portions
of the lateral parts of the abdomen, both in the
large and small intestines. The difficulty is in-
creased because the fluid will change its level with
change of posture, but we may be able to recog-
nize intraintestinal fluid by producing a splash-
ing sound in the bowel upon sudden, deep thrusts
with the fingers, by the fact that the fluid is
limited to, pr is greater on one side than on the

other,
flanks

ACUTE PERITONITIS

other, and by finding that the dullness in the
flanks extends to a higher level than in the su-
prapubic region. Finally, we may puncture the
abdomen if the necessity is really great, and we
will find pus in peritonitis and intestinal contents
if we are dealing with intraintestinal fluid. We
must not forget that solid intestinal contents may
accumulate in the lateral regions when the bowel
is obstructed. These cases show practically no
change upon change of posture.

An exudate which is encapsulated by fresh
adhesions may not show any change upon change
of position and may thus simulate accumulated
intraintestinal contents, the fecal masses may be
differentiated by the fact that in the case of solid
intraintestinal contents, the fecal masses may
be palpable, the consistency of these masses is
doughy, the shape remains altered after the pres-
sure is removed, the dullness is found chiefly in
the left side and hardly at all in the dependent
portions of the right side ; finally by the effect of
emptying the bowel.

Dullness in the flanks may also be caused by
empty, contracted loops of bowel. The dullness
in these cases is also usually unilateral and hardly
changes its location upon change of posture.

We may suspect an exudate in those cases
which show no flank dullness when we find vari-
ous zones of dullness between zones of tympany.

22 ABDOMINAL PAIN

This is not pathognomonic, but should awaken
our suspicion of the presence of an exudate.

We often find a peculiar sweetish or aromatic
odor from the mouth of patients with purulent
peritonitis, a sign which is absent in obstruction
unless there is a co-existing paralytic ileus.
Early, high grade indicanuria speaks against ob-
struction of the colon, but not of the small intes-
tine. Early and marked polynuclear leucocytosis
as well as an early polynuclear leucopenia speak
for peritonitis. Another differential point be-
tween acute strangulation ileus and perforative
peritonitis is the fact that we may observe in
the latter at least the passage of flatus, while no
such passage is present in strangulation ileus.

It must be remembered that air in the peri-
toneal cavity is not pathognomonic of a perfora-
tion, as this may be due to the presence of gas-
producing organisms in the pus of cases of
peritonitis, due to causes other than perforation.
The pain in the latter types of peritonitis is not,
as a rule, as sudden in onset as in perforation
peritonitis. If we see a case of perforation
peritonitis at the very onset, we may observe a
sudden appearance of the before-described air
bubble which may later disappear by absorption;
while in cases where the gas is due to the pres-
ence of gas-producing bacteria, the development
of gas is slower but is progressive.

The diagnosis of the septic type of peritonitis

PERITONITIS — SEPTIC TYPE

is made on the presence of severe signs of intox-
ication. The predominance of the septic features
may be so great, and the local findings may be
so mild, that a diagnosis of sepsis will be made
without even suspecting this type of peritonitis.
The usual signs of sepsis seen in these cases are
pinched face, dry and trembling tongue, cold ex-
tremities, a very rapid and thready pulse, and the
presence of various types of fever, or even of a
subnormal temperature. There is early clouding
of the sensorium, euphoria or delirium, and,
rarely, coma. A characteristic sign of septic
peritonitis is continuous diarrhea with often ten
or more bowel movements daily. The most com-
mon form of this type of septic peritonitis is that
following puerperal sepsis. The pains in septic
peritonitis may be mild or even absent, a fact
which is very striking when we consider the
severity of the accompanying toxic symptoms.
This feature, coupled with the absence of a defi-
nite initial pain, distinguishes it from other types
of peritonitis and from acute strangulation ileus.
Furthermore, the diagnosis is supported by a
polynuclear leucocytosis or even leucopenia, in
which the polynuclears, especially the young
forms, are relatively increased; there is also en-
largement of the spleen and a causative focus of
inflection. The finding of the bacteria in the
blood will also be helpful.

Perforation into a space previously walled off

24 ABDOMINAL PAIN

by adhesions may occur in two different forms.
The initial pain and shock may be followed im-
mediately by signs of local peritonitis, or there
may be a period of intermission between the
initial pain and the subsequent peritonitis. This
intermission may also occur if an empty stomach,
gall-bladder or appendix perforates into the free
abdominal cavity. In either case, the patient
may even feel well enough to work during this
intermission. The combination of initial pain
with shock followed by a period of remission, and
subsequently by a return of the pain, is a se-
quence usually absent in strangulation ileus. The
few instances of strangulation ileus which may
show this intermission are an acute intussuscep-
tion developing into a subacute form, a partial
torsion, or an internal incarceration which is
spontaneously reduced. The differentiation be-
tween localized peritonitis and strangulation ileus
is furthermore made on the determination of
Wahl's and Scklange's signs in these cases of
ileus. Care must be taken not to mistake a local
bulging of gas in cases of localized peritonitis,
for the previously mentioned signs. This local-
ized collection of air can often be made to disap-
pear on pressure, a change which does not occur
in Wahl's or Schlange's signs. The other gen-
eral signs already described under general peri-
tonitis may also occur in the localized form.
The blood findings as previously noted, will

PERITONITIS — UBINARY FINDINGS

help to clear up the diagnosis between these con-
ditions, while the state of the temperature is of
much less value. In some cases, especially in
those with a very rapid course, we may find a
subnormal temperature with rapid pulse. The
higher state of the temperature per rectum in
comparison with that found in the axilla, when
there is about two degrees' difference, will also
speak for peritonitis. Finally, we can make use
of the urinary findings in a small number of
cases. A marked indicanuria soon after the on-
set, that is, on about the second day, speaks
against a strangulation ileus of the colon, provid-
ing the intestines were normal before the onset
of the present trouble. When a marked indican-
uria is present, it will be necessary to distinguish
only between an acute strangulation ileus of the
small bowel and circumscribed perforation peri-
tonitis.

Absence of all peristalsis on auscultation and
palpation speaks rather for a localized peritonitis,
but this absence must be complete, if it is to be of
differential value. Unfortunately, cases of such
a complete absence of peristalsis are rare.

The difficulties are almost insurmountable
when an acute peritonitis exists in the terminal
stages of strangulation ileus. The peritonitis
may result from the bursting of an ulcer in the
stretched walls, the perforation of a decubital
ulcer which was caused by pressure of a con-

ABDOMINAL PAIN

tained foreign body, the wandering of bacteria
through the paralyzed intestinal wall, an occur-
rence which is impossible in a normal bowel, or a
similar condition at the site of strangulation, or
as » result of very extensive nutritional change
in the wall such as occurs in intussusception.

If we find a sudden diffuse tenderness of the
entire abdomen in a case previously examined
and diagnosed as ileus, we may justly suspect the
occurrence of a complicating peritonitis, especial-
ly if there is a rise in temperature, where, for-
merly, there was no fever and where there is a
marked increase in the polynuclears. The same
is true in cases of internal incarceration of the
small bowel, with moderate meteorism which sud-
denly develops a high grade distention with dif-
fuse tenderness of the abdomen. The diagnosis
of this double disease is almost impossible if we
see the case for the first time in the late stages.
We can make a diagnosis only of peritonitis in
these cases. Occasionally, the history may help
us to determine that a chronic stenosis was pres-
ent, but we will be unable to say whether the pres-
ent peritonitis is due to an acute exacerbation
of a chrome obstruction followed by peritonitis,
or to infection of the peritoneum through a de-
cubital ulcer of the bowel in chronic obstruc-
tion.

We must also remember that a circumscribed
peritonitis may cause a stenosis or even a strangu-

CIECUMSCBIBED PEHITONITIS 27

lation of the bowel. This may occur, for example,
when a periappendicial abscess compresses the
ileum or the rectum in the pouch of Douglas. The
latter condition may be recognized by palpation
of the mass per rectum. We also see stiffening
and peristalsis in such cases as well as tenesmus,
passage of considerable slime from anus, and,
later, a patency of the anal opening due to
paralysis of the anal sphincter. But the picture
is not always as complete as presented. The
patient may develop an acute circumscribed
peritonitis around the appendix or an empyema
of the gallbladder. This circumscribed peri-
tonitis may exist for some time, after which the
patient suddenly develops a picture of acute ileus
with collapse. We deal in these cases, not with
a mechanical ileus, but one of a paralytic nature,
due either to spread of the peritonitis or to a
bursting of the abscess. The board-like rigidity,
the flat or concave abdomen, the diffuse abdomi-
nal tenderness, and the other usual signs of peri-
tonitis will aid us in the diagnosis.

In cases of stenosis due to adhesions or com-
pression, and where the onset is very sudden, the
symptoms of obstruction may so overshadow
those of the peritonitis, that the latter may be
entirely overlooked unless the temperature and
blood count are carefully watched.

There is another type of combination of peri-
tonitis and obstruction. A localized, fibrinous

ABDOMINAL PAIN

peritonitis often occurs at the site of a previous
hemorrhage which was caused by an injury to
the abdomen by some blunt object. This type of
peritonitis causes severe localized pains with
vomiting, which, however, disappear in one or
two days. Pain, vomiting, acute collapse, and
finally fecal vomiting appear after a few hours
of apparent relief. The autopsy reveals a fresh
peritoneal adhesion which has caused an internal
incarceration of an intestinal loop. Cases are
known in which a long time, even years, have
elapsed between the original posttraumatic peri-
tonitis and the subsequent formation of the
connective tissue adhesions which caused the ob-
struction. The diagnosis of these conditions is
made on the finding of signs of local peritonitis,
immediately following a trauma with a subse-
quent appearance of evidences of intestinal ob-
struction at a later period.

We occasionally see cases of very acute ap-
pendicitis which run a very severe course, and
which show such signs of obstruction of the bowel
as feeal vomiting, etc. These cases terminate
fatally in a few hours, with severe brain symp-
toms. We find, on autopsy, a slight inflamma-
tion of the appendix and a phlegmonous involve-
ment of the retroperitoneal tissues. It is evident
that these cases die from general sepsis. Septic
intestinal paralysis develops, and the picture of
ileus appears early in the course.

Ileus may also be caused by adhesions from a
previous appendicitis. The obstruction may be
due to adhesion of the intestinal loops, kinking,
knotting, or fixation to the bottom of the pelvis.
Adhesion of the intestinal loops may also follow
an operation for removal of the appendix. We
may or may not observe the initial shock in these
cases.

I wish to describe a form of localized bowel
paresis, that is, a paresis limited to a portion of
the intestine. This occurs in the vicinity of the
diseased focus, and is caused by local edema of
the intestinal wall. This condition may occur in
appendicitis, but it appears later in its course
and not at its onset.

A sudden, overwhelming pain in the abdomen,
usually always colicky in nature, with vomiting,
accompanied by collapse and, in a certain per-
centage of cases, by signs of strangulation ileus,
such as inability to pass feces or flatus, and, final-
ly, the presence of fecal vomiting, must remind
one of an acute interruption of the circulation of
an intestinal blood vessel, especially of the upper
mesenteric vessels. This interruption may be due
to a thrombosis or embolism of the superior
mesenteric artery, or to a thrombosis of the mes-
enteric veins. Sometimes there is an accom-
panying bleeding from the bowel, a finding which
is of importance in the diagnosis. We have other
diagnostic points by which to distinguish this dis-

ABDOMINAL PAIN

ease from acute intestinal obstruction, even if
there is no hemorrhage.

I mention here, among other signs, a note-
worthy finding on palpation. Unfortunately this
sign occurs in only a minority of the cases of in-
farct of an intestinal loop, though it may also
occur in cases of acute intestinal obstruction. This
sign consists of one or more indistinct and tender
tumor masses which show no contractions or
movements of any kind, and which usually give
a dull sound on percussion. In addition, we find
a possible source for an embolus, such as an en-
docarditis, or a reason for a thrombosis of the
mesenteric vessels, such as arteriosclerosis. The
occasional cases of acute intestinal obstruction
which may present similar masses are those of
internal incarceration in which the involved
loops, either empty or filled with blood, appear
as vague, tender tumors, about as large as a
fist, and over which there is a dull sound on per-
cussion. This finding closely resembles the one
described at the beginning of this paragraph
under embolus of the superior mesenteric artery.
It is furthermore possible to confuse this finding
with an intussusception because the findings on
palpation may be nearly alike, and, in addition,
there may also be bloody diarrhea. But even
here, the diagnosis will not be too difficult. In
intussusception, we find a single sausage-shaped
tumor which is capable of showing contractions,

EMBOLISM— TH801I BOS IS

while embolism or thrombosis produce several
masses of intestinal loops which are dead.

Furthermore, I may add that, according to
my experience, the abdomen may show an ex-
quisite, local tenderness in some cases of em-
bolism of the superior mesenteric artery. This
tenderness may lie over the site of the infarcted
loop of intestine and is, perhaps, due to an in-
volvement of the serous covering of the bowel.
The difficulties in the diagnosis will be increased
as the case progresses, because gangrene and
peritonitis ultimately appear. The diffuse ten-
derness and rigidity will usually be considered as
being due to a complicating diffuse peritonitis.

Fluid in the peritoneal cavity may also be
found even in the early stages of embolism of the
mesenteric artery. The presence of colicky
pains speak very strongly for embolism rather
than for peritonitis.

The clinical picture of embolism of the superior
mesenteric artery and of thrombosis of the mes-
enteric veins are quite similar, especially if the
latter sets in rather abruptly. These cases show
sudden hemorrhage from the bowels which is
sometimes associated with hematemesis, sudden
intense, colicky pains, collapse, vomiting, marked
distention and tenderness of the abdomen, and
obstipation or, perhaps, diarrhea. The differ-
entiation from an acute intestinal obstruction or
from acute peritonitis will often be impossible.

82 ABDOMINAL PAIN

We will think of a thrombosis of a mesenteric
vessel when we find malena or a possible cause
for a thrombosis, such as a preexisting ulcera-
tive or inflammatory condition of the bowel,
which may lead to a phlebitis with resulting
thrombosis. Other causes are a diseased portal
circulation, failing heart or arteriosclerosis of
the intestinal blood vessels.

A similar picture, but without the outspoken
signs of ileus, occurs in sudden obstruction of
the portal vein. When the obstruction in the
portal vein is complete and rapid, the patient
complains of a sudden, intense, diffuse abdom-
inal pain, not infrequently associated with col-
lapse, vomiting, and meteorism, in short, much
like the picture one sees in acute peritonitis.
There are additional signs, however, which may
enable us to recognize this acute pylethrombosis.
The patient has, above all, bloody diarrhea, in
which the hemorrhage may be occult or mani-
fest, at times icterus and a diffuse abdominal
tenderness which is most exquisite over the
portal vein. A collateral Caput Medusa; de-
velops, severe cases may bleed from the oesoph-
agus and rectum, more rarely from the nose,
stomach, intestines, and kidneys. Ascites event-
ually develops but may not be seen if the
thrombus becomes canalized or undergoes re-
trogression. A tentative diagnosis can at least
be made when there is also a possible cause, such

as purulent or ulcerative conditions of the bowel,
compression of the portal vein by some circum-
scribed process in its vicinity, luetic scars of the
portal vein, shrinkage of the liver, or syphilis or
malaria of this organ. The suspicion of a pyle-
phlebitis of the portal vein will be heightened
when we find intermittent chills with fever and
tenderness over the portal vein in the presence
of the before-mentioned causes. It is evident
that we are called upon to differentiate between
pylephlebitis with thrombosis and acute peri-
tonitis in the presence of intestinal inflammation
or ulceration, when sudden pain with shock ap-
pears. The inflammatory or ulcerative process
of the bowel which may lead to either process are
acute purulent appendicitis, typhoid, and occa-
sionally dysentery.

We have already mentioned the pedicled or-
gans which may undergo torsion. These are a
wandering kidney or spleen, ovary, tube, omen-
tum, gallbladder or uterine myoma. This tor-
sion may be confused with acute intestinal ob-
struction complicated by strangulation. Practi-
cally speaking, torsion may be ushered in with
sudden, diffuse, colicky pain, eollapse, often with
vomiting, anxiety, abdominal distention and fail-
ure to pass feces or flatus. What is more prob-
able than a diagnosis of strangulation?

Not infrequently, however, one or more chills
accompany the attacks of colie, a finding which

ABDOMINAL PAIK

is rare in ileus. The patient's description of the
attack may help in the diagnosis. For instance,
a wandering kidney which is caught and held in
a certain position may cause pain in the lumbar
region with radiation along the ureter towards
the bladder, urinary tenesmus, and, very often,
tenderness on deep pressure or percussion in the
region where the affected organ may happen to
be located. The wandering organ may some-
times be tender when reached from the vagina
or rectum. Twisting of the ureter wdl also
cause oliguria, with abnormally concentrated
urine, or there may be a reflex anuria. Some-
times there is albuminuria with an appearance of
polyuria after the attack. The remarkable dim-
inution of the total quantity of the urine is
not characteristic of this condition, as it may
also occur in many cases of shock due to other
causes.

The diagnosis of torsion of the pedicled organs
may be made on the symptoms and signs already
enumerated, the location of the pain, and the
rapid appearance of a tumor at the site of the
trouble. Torsion of the ovary will be recognized
by finding a doughy, painful mass per vaginam;
a mass which corresponds to the swollen ovary.
This mass is, in fact, the most reliable sign of
this affection.

Torsion of the spleen is seldom seen. It oc-
curs either as a wandering organ or when the

EXTRAUTERINE PREGNANCY

normal peritonea! supports are missing. The
torsion itself may be caused by a sudden shak-
ing up of the body, as in jumping or running.
Signs of ileus, collapse, and secondary peri-
toneal symptoms are also found in these cases.
The diagnosis is possible only when the nature
of the displaced organ is recognized. Such a
torsion may twist and untwist itself upon fur-
ther brisk motion, or may twist and untwist it-
self several times, thus causing repeated attacks.

Extrauterine pregnancy with rupture of the
sac, or a peritoneal insult caused by the abortion
will be recognized by the gynecological findings,
a history of missed menstruations, the presence
of milk secretion, anemia, collapse, rapid pulse
without fever, subsequent subicterus and the
blood findings showing anemia with absence of
Ieucocytosis.

The following points will aid in the differen-
tial diagnosis between extrauterine pregnancy
and peritonitis. According to recent investiga-
tion, lessened or normal viscosity of the blood
speaks for bleeding in the peritoneal cavity,
while increased viscosity speaks for inflammation
of the peritoneum. The urine in extrauterine
pregnancy may contain urobilin or urobilogen,
while peritonitis cases show an indicanuria.

The difficulties in distinguishing between a
perforation peritonitis and intraperitoneal hem-
orrhage are greatly increased in cases of per-

ABDOMINAL PAIN

foration of the gastro-intestinal tract by an ulce:
with simultaneous erosion of a large blood ves>
sel. In this instance, we see a combination of
the signs of perforation and hemorrhage.

Peritonitis and intraabdominal hemorrhage
may coexist if the ruptured tube of an extra-
uterine pregnancy is adherent to a purulent ap-
pendix. We can make use of a valuable symp-
tom in that case, namely, the reflex muscular
rigidity. This rigidity is very marked in peri-
tonitis, and not nearly so pronounced in extra-
uterine pregnancy. The Abderkalden test for
pregnancy may also be of value in distinguish-
ing between the two diseases.

It will not be very difficult to distinguish
strangulation from torsion, incarceration of
hemorrhoids, crushing injury or inflammation
of the testicle, or inflammations in the groin.
Torsion of an undescended testicle is possible
even while it is still in the abdomen or groin.

A mesenteric cyst may, occasionally, cause a
tearing or kinking of the mesentery when the
cyst shifts its location. The clinical signs very
much resemble those of strangulation and ileus.

The diagnostician is more frequently con-
cerned with cases of renal or gallstone colic. The
severe cases may simulate acute strangulation.
They may also resemble ileus by producing fecal
vomiting and absence of stools and flatus. I
have seen five cases of nephrolithiasis in which

very capable surgeons had performed a lapa-
rotomy for intestinal obstruction only to find
that the ileus was reflex and secondary to the
renal stone.

In this connection, I should like to summarize
the differential points between a stenosis colic
of the bowel and colic occurring in organs not of
a hollow nature, such as the liver, kidney, or
pancreas. Intestinal colic has a wave-like char-
acter in which the pain increases rapidly to its
height and then subsides; the entire wave last-
ing but a few minutes; after which, this wave
of intensity is repeated, but it is always sepa-
rated from the foregoing and following waves
by a period of almost complete relief. The colic
from solid organs is continuous for hours, with,
perhaps, slight variations in intensity during
its course. The wave-like character, with inter-
vals of almost complete relief, are absent in colic
from solid organs, even if the duration of the
pain is short.

In resuming the discussion of renal stone, I
wish to point out some additional signs which
help us to recognize the condition. There may
be one or more chills with the onset of the at-
tack, the pain is localized chiefly in the lumbar
region or the flank, although it is sometimes
found in the epigastrium or lower part of the
abdomen, — the loin is tender on light percussion,
and the skin over this region is hyperesthetic

i.wj blood cdb m

casts may be f onnd in scene eases erf iuLJiuil
obstructioei. bat red fekod eeBs «re absent.
Finally, the X-ray may help to dear up **

diagnosis.

lUnal infarcts, especially when U*^
infarcts of the spleen, may set in with sadden
and intense abdominal pain, with collapse and
ileus. The nature of this attack may be sus-
pected by the fact that the intensity of the pain
remains the same for days, the location is con-
stant and circumscribed, there is no radiation!
there are often chills and fever, and, finally,
there is an obvious source for an infarct, such
as endocarditis, etc Great difficulties maj
arise if there is no apparent source for an in*
farct.

Diseases about the kidney, such as an acuta
paranephritis or hemorrhage into the perirena
tissues may begin with diffuse abdominal pail
and complete stoppage of stool and flatus
Hemorrhage into the iliopsoas muscle resultini

from malignant nephrosclerosis may cause a
reflex, spastic, periodic ileus, with shock and
diffuse abdominal pain.

I may also mention that rare cases are known
in which purulent, suppurative, or hemorrhagic
cholecystitis or pericholecystitis began with in-
tense and diffuse abdominal pain, fecal vomit-
ing, collapse and inability to pass feces and
flatus. We may suspect the gallbladder when
we find a rapidly appearing, tender tumor mass
or tenderness in the region of the gallbladder.
We may also find that the muscular rigidity is
most marked in the upper right quadrant of the
abdomen. Enlargement of the liver, urobili-
nuria, etc., are other symptoms.

Another type of intraabdominal disease which
attracts our attention is acute or subacute pan-
creatitis, pancreatic hemorrhage or necrosis. I
shall consider the three processes together under
the one heading of inflammatory pancreatitis,
because a clinical differentiation, intra vitam, is
not possible. All of the pancreatic diseases may
simulate acute strangulation or perforation peri-
tonitis, as a result of the effect on the solar
plexus and resorption of the pancreatic ferments
in the blood vessels of the intestines, but chiefly
by the direct effect of these ferments on the in-
testinal walls in causing a paralysis of the bowel
with a resulting picture of strangulation or per-
foration. The most striking manifestations of

40 ABDOMINAL PAIN

the above types of pancreatitis are very sudden,
intense, lightning-like abdominal pains which
grow steadily worse, are often diffuse, but sub-
sequently become localized to the epigastrium.
There are also vomiting which only rarely
becomes fecal, marked collapse, and severe
meteorism.

Of further use in the diagnosis is the fact
that pancreatic inflammation and necrosis oc-
cur most frequently in very stout persons, often
in those who have chronically abused alcohol, and
especially in those who have an atrophic cirrhosis
of the liver. These patients have frequently had
attacks of cholecystitis or gallstones, or, perhaps,
luetic or arteriosclerotic disease of the abdominal
blood vessels.

The radiation of the pain in pancreatic disease
is, according to my judgment, of great value.
The patients complain of epigastric pain which
radiates posteriorly, occasionally also to the left
shoulder, but the characteristic manner is a fan-
like radiation downwards to the hypogastrium
as far down as the iliac bones, or even to the
lower extremities or genitalia. In other cases,
the patients complain of pain and tenderness
reaching across the abdomen. This pain is con-
stant and not wave-like, as is the case in intes-
tinal obstruction.

An occasional but important finding is diar-
rhea, perhaps with pancreatic tissue in the stool.

PANCREATITIS

The stools are massive and copious, a finding
which is the contrary to that seen in intestinal
obstruction.

Frequent and persistent vomiting of bile at
the onset speaks rather for pancreatic disease
than for intestinal obstruction high up. Vom-
iting occurs early in obstruction, but the intervals
between the vomiting spells are longer, the vom-
itus is more copious, later contains intestinal
contents, and finally becomes fecal. The vom-
iting of bile in pancreatitis persists throughout
the course. Persistent vomiting which is con-
stantly increasing is found more frequently in
peritonitis than in pancreatitis.

The tenderness in pancreatitis is often limited
to the epigastrium or may be entirely absent in
this region. The abdominal muscles are not
rigid, although they may be tense as a result of
the meteorism, a feature which distinguishes
pancreatic disease from perforative peritonitis
with its diffusely rigid and indrawn abdomen
with tender musculature. Other cases of pan-
creatic neurosis produce a generalized tension of
the abdominal walls, often with diffuse distention,
but even in these cases the chief localization is
in the epigastrium.

We find a different picture in those cases in
which an acute tumor formation has occurred as
a result of inflammation or hemorrhage into the
pancreas. These cases present a strikingly lo-

42 ABDOMINAL PAIN

calized and greatly distended area in the region
of the cecum, the ascending colon, and part of
the transverse colon, a condition which is prob-
ably caused by compression of the transverse
colon by the pancreas tumor. This sign is also
of value in excluding peritonitis. Desjardin's
point of tenderness is also of value. It corre-
sponds to the head of the pancreas and lies about
5 to 7 cm. to the right of the navel on a line
connecting the apex of the axilla with the umbil-
icus. We may occasionally feel areas of indef-
inite resistance in the epigastrium. These areas
of resistance may be due to lumps of fat, necrosis
in the omentum, infiltration of the gastrocolic
ligament, or swollen pancreas. The most pro-
nounced tenderness is found in the epigastrium
and extends to the left lumbar region if there
is extension of the inflammation to the retro-
peritoneal fatty and connective tissue.

I consider the following signs as of importance
in the diagnosis of pancreatic disease; subicteric
or pale, cyanotic color of the face, cyanosis of
the abdominal skin, and urobilin, or even bili-
rubin, in the urine. The latter may be due to
compression of the common duct by the swollen
head of the pancreas or to direct damage of
the liver. There is a clouding of the sensorium,
restlessness, delirium, and sometimes coma if the
patient survives the first 24 hours. Clouding of
the sensorium, delirium, and coma are, however,

PANCHEATIC DISEASE

very rare in obstruction of the bowel. Further-
more, the severity of the symptoms persists in
spite of the emptying of the bowel, a thing which
does not occur in high obstruction, where relief
is obtained even if only gas is passed. The ab-
normally rapid emancipation is a further sign in
favor of pancreatitis.

Clouding of the sensorium also aids us to dis-
tinguish pancreatitis from peritonitis, except in
the cases of severe, septic peritonitis. But even
in the latter, we usually find signs of irritation,
such as delirium rather than stupor or coma,
which are conspicuous and lasting in pancreatic
disease. An abnormally rapid course is also
characteristic of pancreatic disease. The diag-
nosis of pancreatitis will be substantiated by
the appearance of glycosuria and obstipation of
several days' standing without the appearance
of indicanuria. Pancreatic disease is more likely
to be confused with strangulation of the small
bowel than of the colon. Acute perforative or
purulent peritonitis as well as small bowel stran-
gulation show indicanuria if the course is not too
rapidly fatal. We may find a surprisingly high
leucocytosis in spite of the intense collapse
and absence of fever. This leucocytosis speaks
against pure intestinal obstruction and perhaps
against perforation peritonitis. All these con-
ditions except the glycosuria may appear in a
variable degree, or may even be absent, hence the

ABDOMINAL PAIN

diagnosis cannot always be made with certainty.
These signs will also be useless if the pancrea-
titis is complicated by a secondary, fulminating
diffuse or local peritonitis, local collection of
pus, retroperitoneal phlegmon, general sepsis, or
thrombophlebitis of the portal or mesenteric
vein.

Pancreatic necrosis in which an early icterus
appears may be confused with disease of the
liver or biliary tracts, especially if collapse
is present in the latter. The pancreatitis will
be recognized by the long duration and intensity
of the collapse, the absence of striking tenderness
over the incisura hepatis, or the absence of a
possible cause for the inflammation of thrombosis
of the portal vein. The diagnosis of pancreatitis
becomes clearer if we can palpate a tumor above
the navel. This tumor may be due to purulent
pancreatitis or to fat necrosis. The functional
tests of the pancreatic activity may also aid us,
especially if the course extends over weeks. The
presence of sugar in the urine makes the recog-
nition of pancreatic disease even more probable.

Pancreatic stones or cysts are chronic condi-
tions which may produce severe colic with shock
and unconsciousness, but not the signs of ileus.
Pancreatic cysts may be suspected when we find
a cystic tumor in the supraumbilical region
which is accompanied by the above-described
colicky pains. Such a recurring colic closely

PLUMB ISM

resembles a recurring intestinal obstruction, es-
pecially a recurring volvulus.

I shall finish the discussion of the conditions
which may resemble strangulation ileus by con-
sidering chronic lead poisoning. These cases of
plumbism present very severe diffuse colicky
pains in the abdomen, at least moderate collapse,
constipation, and intense vomiting. The diag-
nosis is made on finding a markedly indrawn,
rigid abdomen which is not tender on pressure, a
pulse which is strikingly slow during an attack
of pain, and a blue lead line on the edge of the
gums. A history of the patient's occupation may
also help in the diagnosis. The patient need not
be a painter, but may be a worker with white
felt hats, white gloves or umbrella handles,
cooking utensils which are repaired with lead.
Drinking cider from lead containers may also
cause the disease. Further signs of chronic
lead poisoning are high blood pressure, accent-
uated second aortic tone, and stippling of the
red blood cells. The diagnosis can be made on
the foregoing symptoms even in the absence of
arthralgia, typical lead palsies, and changes in
the joints, vessels, brain or kidney.

Severe, Diffuse Abdominal Pain, with Shock
but without Ileus

When a patient complains of unusually severe
dominal pain with a feeling of impending

ABDOMINAL PAIN

death but without the signs of ileus, we must not
overlook the fact that we must consider those
diseases discussed in the previous chapter. Ileus
is always present in intestinal obstruction and is
a very important symptom of this disease, but
the same symptom complex may also occur in
other conditions.

A picture resembling acute peritonitis may be
seen in the acute onset in some cases of Addison* $
disease, sudden blocking of the adrenal veins,
hemorrhagic infarcts, apoplexy into the adrenals,
or any cause leading to acute insufficiency of
these organs. The patient is attacked by sudden
diffuse abdominal pain, severe vomiting, singul-
tus and pains in the calves of the legs. He
appears collapsed, has obstinate constipation or
diarrhea, the pulse is rapid and weak, the abdo-
men drawn in and concave, and the abdominal
muscles rigid, and the patient dies in coma.
Autopsy reveals no trace of peritonitis or dis-
ease of the organs, but a close search will reveal
distinct tuberculosis of the adrenals. The diag-
nosis is facilitated if the patient is known to have
suffered from Addison's disease or to have had
the characteristic brownish pigmentation of the
skin and mucous membranes. Some cases of
Addison's disease have a tenseness of the abdom-
inal muscles and of the calves of the legs. The
pigmentation may not be present in very acute
cases. Finally, we must not mistake pigmenta-

MESENTERIC CYST 47

tion of the skin from other sources for the pig-
mentation of Addison's disease. The mucous
membranes as well as the skin are pigmented in
disease of the adrenals.

Sudden, violent pain in the abdomen, with col-
lapse, followed in a few hours by death, must
remind us of a rupture of an abdominal artery
into the free peritoneal cavity. The vessels
usually affected are the abdominal aorta or its
branches, and especially a mycotic aneurism of
the splenic, superior mesenteric or common iliac
arteries. We will especially suspect this condi-
tion in the presence of rapidly accumulating fluid
in the peritoneal cavity with anemia. The knowl-
edge that such an aneurism existed previously
will be of great help in the diagnosis.

A very important symptom of mesenteric cyst
is abdominal pain which comes on suddenly, is
repeated, is nearly always colicky, and is some-
times overwhelming in severity. It may occur
during apparent good health or during the pe-
riod of vague, chronic dyspeptic symptoms, such
as vomiting, constipation, and slight pains in the
abdomen. The pains and dyspeptic symptoms
are caused by the change in position of the
movable cyst with resulting tearing, stretching,
or kinking of the mesentery. I have already
mentioned that this condition may simulate intes-
tinal obstruction by producing meteorism, vomit-
ing, and stoppage of stools and flatus.

48 ABDOMINAL PAIN

Tumors of the great omentum produce very
similar pains, which are often located in the
epigastrium. The nature and severity of these
disturbances are quite similar to those produced
by tumors of the mesentery regardless as to
whether the growth is solid or cystic.

We have already said that we must not forget
to consider the possibility of a torsion of a wan-
dering kidney with resulting acute hydronephro-
sis when we believe that we are dealing with a
renal colic We must also consider some other
conditions in this connection as, for instance, rare
cases of perforated periappendicitis which have
extended high up toward the kidney and inflam-
mation of the appendix which lies in the retro-
peritoneal tissues, or some cases of acute para-
nephritis resulting from a rupture of a renal
abscess. The patient may complain of severe,
diffuse pain in the abdomen as well as of pain
in the lumbar region in the conditions mentioned
in this paragraph. We will be aided in the diag-
nosis by finding tenderness in one or both flanks,
especially on deep percussion, hyperesthesia of
the skin in these regions, and marked pain
toward the lumbar region on deep pressure from
the anterior abdominal walk The most substan-
tial points for the diagnosis are, however, the
appearance of a swelling in the lumbar region
even though it be only of mild degree, perhaps
a resistance or tumor formation in this region,

NEPHRITIC PARALYSIS

eventually a redness or edema of the skin, ex-
tending even to the iliac region, unilateral mus-
cular spasm of the long back muscles, and,
according to my observation, a shortening of the
distance between the tenth rib and the anterior
superior spine on the diseased side.

Another disease in the kidney region which
may sometimes cause diffuse pain over the abdo-
men with collapse, is the so-called apoplexy
about the kidney region. This may occur as a
single hemorrhage with a stormy onset or as
repeated bleedings with formation of a hema-
toma in the pericapsular tissues of the kidney.
At times it is caused by primary disease of the
kidneys, such as carcinoma, sarcoma, abscess or
tuberculosis of this organ, arteriosclerosis or pre-
existing interstitial nephritis, and, finally, hem-
orrhage of the adrenals. We may find sudden
diffuse abdominal pain, early collapse, and signs
of paresis of the bowel. Soon a resistant mass
appears in the lumbar region which may rapidly
develop into a tumor around or below the kid-
ney, and which may be palpable in the flanks
or even downwards in the iliac regions. At
times, we find a transitory anuria or albumin and
blood in the urine.

An appreciable rise in temperature occurs if
the hematoma becomes infected or purulent. A
symptom, which, in my opinion, is very impor-
tant and striking, is the high-grade acute anemia,

50 ABDOMINAL PAIN

resembling that which occurs in all forms of
internal hemorrhage. Internal hemorrhage from
sources other than the pararenal region are,
however, accompanied by collapse. Rupture of
the liver with internal hemorrhage produces
bradycardia, while rupture of the kidney shows
blood in the urine. The appearance of subcu-
taneous hemorrhage under the skin of the lumbar
region is another symptom which may aid in a
diagnosis. The knowledge of a pre-existing renal
lesion which may lead to such a hemorrhage may
also attract our attention to the proper region.

The picture described in the previous para-
graph is of importance because it shows that a
retroperitoneal disease may cause diffuse abdom-
inal pain. This is even more conspicuously shown
in the case of traumatic hematoma in the renal
region. These cases may cause diffuse abdom-
inal pain with rigidity, vomiting, rapid pulse,
and slight fever; in other words, pseudoperito-
nitic symptoms.

The abdominal or gastric crisis of tabes rarely
begins so suddenly that it may be confused with
the afore-mentioned conditions. Even if the crisis
is the first symptom of the tabes, we may make
the diagnosis on the fact that the patient has had
no previous abdominal pain, that the attack lasts
for days and weeks and ends suddenly, that the
pulse rate and blood pressure are increased, and
that the spinal fluid gives the characteristic find-

TABES ANGINA PECTORIS

Iings. Other signs of tabes may also be present.
Such crises may be due to causes other than
tabes, as, for instance, spinal lues, syringomyelia,
multiple sclerosis, myelitis, diabetes, Basedow's
disease, tuberculosis, syphilis, neoplasms, actino-
mycosis of the intraspinal roots, chronic morphin-
ism, disease of the cceliac plexus, pancreatitis,
lesions of the lesser curvature of the stomach or
of the cardia, retroperitoneal glands, and aneu-
rism of the abdominal aorta. The pains are
crisis-like, — that is, they are constant in nature,
begin suddenly, are severe in their course, and
end abruptly, leaving the patient in an appar-
ently good state of health.

There is one condition which we must always
remember in the presence of acute abdominal
pain accompanied by a feeling of anxiety. This
is subdiaphragmatic angina pectoris. The pains
may be in the epigastrium, over the portal vein,
or in the lumbar region, with radiation to the
lower limbs. There is practically no vomiting;
the pains are burning or oppressive and not
colicky, and reach behind the lower part of the
sternum. There is no tenderness in the epigas-
trium or over the solar plexus, unless there is a
periaortitis or arteriosclerosis of the abdominal
aorta. The diagnosis will, furthermore, be made
on the presence of a sensation of anxiety and
precordial oppression when the blood pressure
is increased, as after excitement, bodily motion,

52 ABDOMINAL FAIN

or abuse of nicotine. The second aortic tone is
accentuated and ringing. There is some arterio-
sclerosis of the peripheral vessels, the patient
avoids all movement during the attack, there
may be a history of lues or a positive Wasser-
mann, especially if the patient is of the age when
attacks of angina pectoris are most frequent.
Furthermore, the attacks are constant in location
and nature; that is, they do not proceed from the
heart region at one time and from the abdomen
at another, but always from the same place.

Rupture of the heart or, what is more com-
mon, rupture of the thoracic aorta, may be
followed by severe abdominal pain with shock,
vomiting, meteorism, and death in a few hours.
Acute anemia practically never occurs. The
pericardial dullness is increased, there is no
abdominal tenderness, and the pains extend be-
hind the sternum or to the shoulders, especially
on the left side.

There are also some extraabdominal conditions
which must be remembered. These are pneu-
monia, bronchopneumonia, pleurisy, empyema
and pneumothorax, but especially acute dia-
phragmatic pleurisy. The latter is very likely
to produce early and continuous vomiting, sin-
gultus, tension of the abdominal muscles, and no
passage of stools or flatus. This picture is
especially likely to occur in children and may
resemble acute peritonitis.

Pleuropulmonary diseases of this nature pro-
duce a hyperesthesia of the skin, while there is
little or no tenderness on deep pressure. There
are, furthermore, increased respirations, cough,
reddish color of the cheeks, full pulse, headache,
and the typical, common signs as well as findings
on X-ray examination.

Diaphragmatic pleurisy is characterized by
tenderness along the phrenic nerve, lagging of
one-half of the thorax and decrease of the ab-
dominal tension during respiration.

Two other extraabdominal conditions which
deserve mention are acute suppuration of the
inguinal glands and acute incarceration of hem-
orrhoids. The diffuse, abdominal pain may be
so severe that the patient may forget about the
real cause in the groin or anus, and this may
lead to the confusion of this trouble even with
acute peritonitis. A careful examination will,
however, reveal the true cause.

Other possibilities are poisoning with corrosive
sublimate, especially when accompanied by
bloody or ordinary diarrhea. The diagnosis will
be simplified if there is corrosion about the mouth
or if the vomitus is examined. The poisons which
produce violent abdominal pains are strong acids
and alkalies and acute arsenic, lead, or mercury
poisoning. We must also consider the possibih'ty
of the subsequent secondary perforative perito-
nitis, especially in the subacute cases.

54,

ABDOMINAL PAIN

In passing, we may mention acute anthrax of
the intestines, which is associated with severe
abdominal pain. This disease is characterized by
collapse, high grade circulatory failure, vomiting,
diarrhea, meteorism, and dyspnea. The diag-
nosis will be made on the bacteriological findings
in the feces, blood, and spinal fluid, and on the
presence of blue, swollen gums.

It is not sufficient simply to diagnose the
presence of one of the foregoing diseases. We
must also try to recognize the immediate cause
of the acute abdominal pain, a symptom which
may be caused by several different factors in the
same disease. A discussion of typhoid fever, as
an example, will make my meaning clear. We
are accustomed to associate severe abdominal
pain in typhoid with perforation, but this pain
and collapse may be due to a ruptured gland
which has been infected with typhoid, typhoid
abscess of the spleen, or purulent typhoid salpin-
gitis. We must also remember that typhoid may
begin like an acute appendicitis and may be
followed by a real periappendicitis, and even by
degeneration of the abdominal muscles.

Severe, Diffuse Abdominal Pain, without
Shock

When a patient complains of severe abdominal
pain without shock, we must try to orient our-
selves by determining the location, radiation and

PEHITONITIS

character of the pain; the time of day at which
it appears; repetition of the attacks; and, if
possible, the immediate cause as well as influence
of motion, change of posture, and the effect of
pressure. We must also consider the objective
findings and the associated symptoms during and
after the attack. We must, furthermore remem-
ber that a localized pain may later become dif-
fuse, and that a diffuse pain often has a point of
greatest intensity.

The first condition which occurs to us in the
presence of diffuse abdominal pain of this nature
is acute peritonitis. The pain in this disease is
rarely colicky, usually sudden in its onset, very
intense, continuous, and rapidly increasing in
severity, so that its very height is reached in a
short time. Exacerbations or remissions are
either very moderate or absent. Most of these
cases will prove to be of the acute purulent type,
but they may also be cases of acute tuberculous
peritonitis.

The diagnosis of the purulent type will be
based on the presence of fever, vomiting, singul-
tus, difficult urination, diffuse meteorism, obsti-
pation and no passage of flatus. The patient
keeps very quiet, the respirations are rapid, shal-
low, and of the costal type, the pulse is weak
and rapid, and there is diffuse tenderness and
constant rigidity. We also find a leucocytosis
and a difference of two or more degrees between

56 ABDOMINAL PAIN

the rectal and axillary temperatures. Pain on
rectal examination is also found if the peritonitis
extends to the pouch of Douglas. The picture
will be greatly changed in septic or gangrenous
peritonitis and will resemble the picture already
described under septic peritonitis.

Acute tuberculous peritonitis presents a pic-
ture in which the muscular tension is not marked;
there is no striking leucocytosis and no positive
Diazo reaction; the serous exudate is apparently
sterile, but may show bacteria on animal inocula-
tion. The fluid may contain more polynuclears
than lymphocytes. The level of the exudate
changes promptly with change of position. There
may be no other apparent tuberculous focus, as
acute tuberculous peritonitis may be the only
manifest sign of the infection, for example, when
it follows tuberculosis of the intestine.

We shall now consider the various types of
purulent peritonitis according to the causative
bacteria. The usual bacteria causing peritonitis
are the common pus organisms, colon bacilli,
typhoid and paratyphoid, gonococcus, pneumo-
coccus, FriedUender bacillus, and other similar
encapsulated bacilli. Mixed infections are also
rather common. The early clinical signs of peri-
tonitis, the so-called peritonism, is due to the
general hyperemia and to a serous exudate of
the peritoneum, even before there is any visible
gross affection of the tissue. This exudate need

PERITONISM

not always be sterile, although we consider this
type of peritonitis as due to a chemical toxin.
Such cases may present meteorism, pains, and
tenderness, sometimes even dullness in the de-
pendent portions of the abdomen. In contra-
distinction to a genuine peritonitis, we find that
the general condition of the patient is good; the
pulse corresponds to the temperature and will
hardly exceed 100 per minute. The muscular ten-
sion is not so diffuse as in real peritonitis and will
be localized to the affected region, even if there
is general tenderness. In the latter case, the ten-
derness will be most intense over the site of the
lesion. The respiratory movement will be absent
or lessened at the site of the trouble, and the
abdominal reflexes may be missing at this region.
The liver dullness is not diminished, a finding
which occurs in true peritonitis. The symptoms
tend to concentrate towards the diseased area as
the course progresses. This picture is seen es-
pecially where a perforation has occurred in a
previously walled-off space, as in ulceration or
carcinoma of the intestine. When the peritonism
is caused by disease of the gallbladder or female
genitalia, the signs of these conditions will appear
in combination with those of the peritoneal irri-
tation. Peritonism may also occur in Addison's
disease and in acute infection of the intestines,
such as anthrax, paratyphoid, and, occasionally,
cholera.

58 ABDOMINAL PAIN

The pneumococcic peritonitis has the peculiar-
ity that the diffuse pain and tenderness become
centralized soon after their onset, chiefly over
the ileocecal region. This affection is found
especially in young girls, less often in adults.
The underlying pathology is usually a localized,
exudative, purulent peritonitis, most commonly
caused by perforation of the appendix, peri-
appendicitis, pericholecystitis or pelvic perito-
nitis following disease of the female genitalia.

An early and important symptom in pneumo-
coccic peritonitis is diarrhea. This accompanies
the other peritonize symptoms, such as severe
pain, vomiting, and fever. The process tends to
localize because the fibrino-purulent exudate,
which forms in the early stages, tends to wall off
the process. The most common localization is
about the umbilicus and the lower right part
of the abdomen. This localization is often the
cause for confusion with appendicitis. The gen-
eral condition of the patient is usually good, and
the course is comparatively benign. There is a
polynuclear leucocytosis, herpes, and a rich fibrin
content in the blood.

A condition which may cause confusion with
general peritonitis is periarteritis nodosa, or,
more specifically, mesoperiarteritis nodosa. This
disease begins with the general symptoms of in-
fection, such as fever, increased pulse, anemia,
marked pains in the extremities, and profuse

sweating. Nephritic symptoms and peritonism
often appear after a few days. The final diag-
nosis will be made upon palpation of the small
aneurismic bulgings in the surface arteries of
the skin and muscles of the intercostal spaces
with, perhaps, an eosinophilia. The Wassermann
reaction may be of value if the disease is of syph-
ilitic origin.

There are extraperitoneal causes of the type
of abdominal pain under discussion. The cause
may be a rupture of a hydronephrotic sac, in-
volvement of the coeliac plexus, and acute or
purulent inflammation of the retroperitoneal tis-
sue. The cause of the retroperitoneal inflamma-
tion may be a recent one or one which has existed
for a long time. It may even be due to an
inflammation of the inguinal glands or to acute
bilateral renal infarcts resulting from an endo-
carditis.

Another cause is acute pyelitis, especially in
pregnant women. This begins with chills and
high fever, but the pain is most marked in the
lumbar region, with tenderness over this place,
hyperesthesia of the skin, tenderness of the
upper part of the psoas muscle, intermittent
fever, and characteristic urinary and cystoscopic
findings.

A similar picture may be produced by inflam-
mation, either simple or purulent, of the peri-
renal tissues. The patient will complain of pain

ABDOMINAL PAIN

in the lumbar region, especially below the twelfth
rib. There will also be local hyperesthesia, rigid-
ity of the lumbar muscles, and local tenderness
on deep percussion. We often find a scoliosis
of the lumbar spine. The urine is not cloudy,
but contains bacteria. These symptoms are near-
ly always accompanied by remittent or intermit-
tent fever, and early chills.

Sclerosis of the mesenteric arteries or veins and
chronic phlebitis cause severe colicky pains which
may also be boring in character. These may
appear at intervals of months or days of appar-
ent good health. Sclerosis or phlebitis of the
veins can be diagnosed only if there is thrombosis
of the portal or intestinal veins. The picture of
sclerosis of the arteries will differ according to
the distribution of the process, that is, according
as to whether it is a local sclerosis of the superior
or inferior mesenteric arteries or a general dif-
fuse sclerosis.

There is a group of symptoms in the local
form named by me Dyspragia Intermittens An-
giosclerotica Intcst'm-alis which is characterized
by local "dead" meteorism, a condition in which
there is local pain and meteorism but no visible
or audible peristalsis over the affected area.

The patients with diffuse sclerosis suffer from
attacks or diffuse abdominal pains, which rapidly
increase in severity and last for a few minutes
to several hours. The abdomen is tense and

DIFFUSE SCLEROSIS

distended, the diaphragm is pushed up high in
the thorax, the pulse is accelerated, and the pa-
tient complains of oppression, palpitation, and a
sticking sensation over the precordium. It is
also very important to find that there is no peri-
stalsis in the distended abdomen. The patient
states that the pain continues as long as there is
absolute quiet in the abdomen, and that the pain
begins to disappear when he feels gurgling in
the intestines. This symptom is not absolutely
pathognomonic, as it also occurs in reflex paresis
of the intestine resulting from any remote pain-
ful source, as kidney stone, etc. The history is
variable; sometimes the patients state that the
cause is food which produced flatulence; others
blame bodily motion or mental excitement.

In my experience, the majority of cases feel
the pain after walking; another group of patients
feel it when they are in the horizontal position,
especially at night. The latter group must get
out of bed with the feeling that they are going
to have a bowel movement, but none comes.
When the bowels do move, the patients feel much
easier. The feces contain occult or a small quan-
tity of manifest blood. Sometimes there is
strangury and, occasionally, difficulty in uri-
nation. The patient may also lose weight, es-
pecially if his sleep is much disturbed by the
attacks. Further points are the age of the
patient, abuse of tobacco, and evidence of arterio-

ABDOMINAL PAIN

sclerosis elsewhere. Finally, we may make use
of the therapeutic test by employing theobromine
and noting that the attacks disappear for months
and leave only a tendency to attacks of meteor-
ism and flatulence.

I may add that aneurism or sclerosis of the ab-
dominal aorta may cause the same symptoms as
those resulting from involvement of the mesen-
teric vessels. Aneurism will also produce pains
in the back of the abdomen with radiation to the
hypogastrium or scrotum. Simple sclerosis of
the abdominal aorta is often characterized by a
girdle pain and is accompanied by weakness in
the legs. Both the pains and weakness disappear
if the patient remains at absolute rest. The diag-
nosis will be more easily made if we find the signs
of thickening of the aorta, such as a convex or
serpentine course of this vessel, with the convex-
ity to the left, the presence of a murmur on
slight pressure over the aorta, and a systolic mur-
mur when no pressure is made in this place. The
pains in general sclerosis of the abdominal ves-
sels may also be explained by the fact that the
intestinal wall may undergo a sclerosis or fibro-
sis as a result of the change in the blood vessel
walls. This change in the walls leads to a local
paresis of the bowel. The segment immediately
above this part becomes hypertrophied and con-
tracts very strongly in the attempt to overcome
this paretic obstruction. This abnormally stroi

BANTI 8 DISEASE — POLYCYTHEMIA

Bfl

I contraction may be the immediate cause of the
pains. Sclerosis of the intestinal veins produces
pains which are due to the resulting thrombosis.
We sometimes find boring or colicky pains in
Banti's disease. The special symptoms of this
disease are splenic enlargement, anemia, leuco-
penia, enlargement of the liver, ascites and

» icterus. Subsequently there is a shrinkage of the
liver, likewise swelling of the lymph glands and
hemorrhagic diathesis. The sequence of the ap-
pearance of the symptoms, as enumerated, is of
importance.

Polycythemia also leads to attacks of pain in
the epigastrium. These pains may be diffuse or

» localized, and they may be colicky or of an
indefinite nature. The diagnosis will be difficult
because polycythemia is often associated with
arteriosclerosis and increased blood pressure,
both of which may, of themselves, lead to the
symptoms under discussion.

Chronic disease of the pancreas may also cause
this type of abdominal pain.

Occasionally, the pain in duodenal ulcer, which
is typically localized near the gallbladder region,
may spread out around the navel and be present
in the entire lower abdomen. The differentiation
from the pain of arteriosclerosis or nicotinism
will be made on the nocturnal appearance of the
pain, the lessening of the pain on intake of food,
the presence of occult malena, hypermotility,

64 ABDOMINAL PAIN

and on the characteristic X-ray
findings. This type of diffuse pain may be due
to involvement of the coeiiac plexus. The possi-
bility of such a cause for the pain was demon-
strated to me at an autopsy of a case of carci-
noma of the stomach in which the coelic plexus
was also involved.

Furthermore, all cases of acute intestinal ob-
struction without signs of acute strangulation
belong to this group. We must repeat that the
location of the pain and tenderness does not al-
ways correspond to the site of the obstruction.
From a diagnostic point of view, we must con-
sider two groups of cases. Cases of the first
group are those with bowel disturbances lasting
for some time. This is the larger group and com-
prises the cases with chronic obstipation, perhaps
alternating with diarrhea, rarely only chronic
diarrhea. Occasionally the history may suggest
obstruction, the patient may describe movements
seen or felt in the abdomen or a sensation as if
something suddenly stopped in this region. These
symptoms may suddenly become more severe,
and the picture may then resemble acute obstruc-
tion. The reason for the sudden obstruction may
be a dietetic error, a large residue of undigested
food, or rapid eating of large morsels. The
stagnating food may cause a rapidly developing
inflammation of the mucosa, and this swelling
may become severe enough to cause a stenosis.

GALLSTONE ILEUS

Another cause is kinking of a loop of bowel
proximal to the stenosis. The same result may
also be caused by flatulence, trauma, or diarrhea
in which the peristalsis is increased.

The second group has, as a rule, no premon-
itory symptoms of the causative factor. The
obstruction may be caused by gallstones, less
often by other foreign bodies, and very rarely
by fecoliths. We must remember the possibility
of tumors, scars, or peritoneal adhesions both in
this and in the first group. The diagnosis of
gallstone ileus will be comparatively easy where
there is a history of previous gallstone disease,
but, as a rule, the stones pass into the duodenum
via a perforation and often produce no symp-
toms. The peculiarity of gallstone ileus lies in
the low-grade meteorism in spite of the presence

^of complete obstruction and severe symptoms.
Flatus and even feces may be passed even in the
presence of fecal vomiting. If the stone is
jammed high up in the duodenum, we find bil-
iary vomiting, a characteristic sign of duodenal
obstruction. We may find evidences of obstruc-
tion lower down in the bowel as the stone wan-
ders outwards. This wandering is characterized
by pains, first in the pyloric region when the
stone passes into the duodenum, later by pains
in the umbilical region, and finally at the site
of the cecum if the stone remains in this region
for a long time. The change in location of the

66 ABDOMINAL PAIN

stone may be followed by palpation and rectal
or vaginal examination. Tbe stone does not al-
ways wander as just described but may produce
a complete obstruction anywhere in the intes-
tinal tract.

We must also include cases of intussusception
which are unaccompanied by signs of strangula-
tion. I wish to point out in this instance that
fecal vomiting may be absent and that the ob-
struction may not be complete. On the contrary,
a very valuable sign is diarrhea with bloody or
blood mucus stools about ten to twenty times a
day. Palpation of the intussusception tumor
will be a decisive finding.

The picture of intussusception, especially when
in the ileocecal region, may be imitated by pur-
pura intestinalis with bleeding into the cecum or
ileum and very rarely into the appendix. The
bowel becomes paretic and may produce symp-
toms resembling ileus. The diagnostic features
are drawing in of the abdomen, bleeding from
various places, and joint symptoms. The pic-
ture of peritonitis may be closely simulated if
there is bleeding in the peritoneal cavity or hem-
orrhagic ascites.

Both intestinal obstruction and peritonitis may
begin with pain and ileus. Intestinal obstruction,
however, produces no tenderness or rigidity of
the abdomen and no initial increase in the tem-
perature. The breathing is abdominal, and there

is no great increase of the pain on deep inspira-
tion. Peristalsis may be visible or heard, and
the increased contractions may even produce
metallic sounds. Comparison of the anal and
axillary temperatures as already described may
be of value.

In rare instances, localized purulent peritonitis
may produce a local muscular rigidity, absence
of the abdominal reflexes on the affected side,
hyperesthesia of the skin in this region, and a
slight dullness or sensation of resistance over the
disease area. The symptomatic ileus, which de-
velops rapidly, retrogresses, and the intestinal
contents may be pushed from one distended loop
into another with a gurgling sound. The pas-
sage of flatus speaks rather for a circumscribed
peritonitis, as this phenomenon is not present in
obstruction, except in intussusception or when
due to gallstone impaction within the bowel.

Ileus due to a foreign body within the bowel
may occasionally be accompanied by fever and
thus make its differentiation from a circum-
scribed peritonitis very difficult.

Acute, diffuse, colicky, abdominal pain may
be caused by incomplete stenosis as well as by
complete obstruction. The symptoms depend
on the localization of the obstruction. A patient
with stenosis of the bowel may show local stif-
fening or peristalsis over the small intestine, and
he may hear squirting sounds in this region. The

68 ABDOMINAL PAIN

pain is chiefly around the navel and radiates to
the back. Colic may be absent for a long time
in chronic stenosis of the colon. This colic, when
it appears, will be located along the colon, es-
pecially in its transverse segment, and will travel
from right to left. Stenosis of the lower seg-
ments of the bowel may produce pain in the
lower parts of the abdomen. In this connection
it is interesting to remember that patients with
stenosis of the colon may complain of pain in the
stomach region.

Acute, more or less diffuse and colicky pain
may be produced by acute, subacute, and even
chronic peritonitis, usually tuberculous in nature.
Such pains are not present in the early stages of
carcinomatous peritonitis, and this point may be
considered in the differential diagnosis. Symp-
toms of peritonitis or ileus may accompany these
pains, especially in the cases of so-called perito-
nitis tuberculosa enteroparalytica. It must also
be remembered that a fluid exudate in the perito-
neal cavity may not be present, and in such cases
we may depend on the presence of fever and
rapid emaciation. These diffuse pains may be
present during the course of tuberculous perito-
nitis as well as at the onset, but in the former
instance the pain will be due to complications,
such as stercoral abscess of the intestinal wall,
ulcer, perforation of such a tuberculous ulcer, or
adhesions between intestinal loops.

Sue

an aft

PUHULENT PEEITONITIS

Such diffuse colicky pains may also be due to
an after-effect of an acute fibrino-purulent peri-
tonitis, not tuberculous in nature. This type of
cases is associated with meteorism, diarrhea, and
vomiting, especially after food which leaves a
large residue, or after heavy meals. The diagno-
sis will be based on this history and on the pres-
ence of tenderness. The tenderness may be dif-
fuse or localized to several areas if there were
several such foci at the onset of the disease.
Rigidity, dullness on percussion, and a vague
tumor may also be found in these cases. Leu-
cocytosis, occasional fever in the evening, and a
gradual recrudescence of the symptoms will fur-
ther characterize this disease.

A similar subacute or even chronic picture may
occur in typhoid. This peritoneal involvement
need not be due to a perforation but may be
caused by a migration of the bacteria into the
peritoneal cavity from a slowly progressive
necrosis of some abdominal organ.

Furthermore, we must mention the simple
intestinal colics which are due to irritation of the
intestines by various causes, or which arise by a
reflex route. We must also consider inflamma-
tory, ulcerative, vascular, or functional nervous
disease of the bowel. The diffuse pains and ten-
derness are produced by peritoneal irritation, and
the localization depends on the site of the original
trouble.

70 ABDOMINAL PAIN

We must not forget that hysteria may cause
such pains either as a purely hysterical attack or
as a provocation by enteritis, etc Rapid change
of symptoms, superficial tenderness with absence
of tenderness on deep pressure, ready suggesti-
bility, evidence of other hysterical signs and ab-
sence of genuine peritonitic findings, especially
of shrinkage of the liver dullness, may all aid
in the diagnosis of hysteria. The abdominal
reflexes are absent, and there will be no sign of
peritoneal irritability such as one finds in peri-
tonitis. The patient shows evidences of pain in
genuine peritonitis if the hand, which was press-
ing deeply on the abdomen, is suddenly removed.
This is a sign of peritoneal irritability found in
cases of peritonitis, but not in hysteria.

In the differentiation of simple, localized, in-
testinal colic from intestinal obstruction, we can-
not lay much stress on the etiological factor un-
less it be lead poisoning. Any irritation of the
bowel, either reflex or actual, may be followed by
simple intestinal colic. They may produce pains
in an ulcerative condition of the bowel, or they
may be the first sign of an actual obstruction.
I wish to emphasize the fact that a chronic ste-
nosis may remain dormant for a long time and
then suddenly give rise to symptoms of an acute
stenosis. Acute and chronic intestinal catarrh
may also cause colic, and we must remember that

CHRONIC STENOSIS — SIMPLE COLIC

this catarrh may also be the result of a chronic
stenosis.

The striking difference between a simple colic
and one due to stenosis is the intensity of the
pain and the general effect on the body. Un-
bearable pains, prostration, increased pulse, and
extremities speak for stenosis if we are not deal-
ing with a hypersensitive patient. Vomiting and
collapse may, however, be caused by severe ca-
tharsis. The shape of the feces and the palpa-
tion of the fecal masses in the abdomen are of
no very great value and often lead to error. A
copious stool either spontaneously or after ca-
tharsis is not a positive proof against stenosis.

Splashing and gurgling sounds are a valuable
aid in excluding such extraintestinal conditions
as gallstones, renal calculus, or peritonitis. Ul-
ceration of the bowel may produce attacks sim-
ilar to those caused by the above-named extra-
intestinal conditions, but will be differentiated
by the splashing sounds, migrating nature of
the colic, and by the comparatively short duration
of the intense period of the attacks. The attack
may end with the passage of a fluid bowel move-
ment of a distinctly bad odor, or the pains may
be increased as a result of the increased peristal-
sis. Occult blood is also very often found in
ulceration of the bowel. There may be spirilla;
or the specific organisms of dysentery in the
feces.

ABDOMINAL PAIN

Lead colic distinguishes itself by the fact that
the pain begins in the region of the navel and
later becomes diffuse. Furthermore, there is
constipation before, during, and after the attack,
the abdomen is drawn in, and the pain persists
for several hours and may be increased by pres-
sure. Vomiting is frequent and severe, the pulse
is slow and of high tension, the second aortic tone
is accentuated, and the history may point to lead
as the cause of the trouble.

Another type of colic is the so-called appen-
dicular colic which is caused by a cramp-like
contraction of the appendix musculature in an
attempt to force out some pathological contest,
such as a fecal stone, foreign body, or plug of
mucus. It may also occur in simple catarrhal
appendicitis, when adhesions or kinking are pres-
ent. The pain is diffuse in many cases, meteor-
ism is present all over the abdomen, the abdom-
inal walls are tense and tender, and there are
fever and vomiting. Peritoneal symptoms may
be present in the cases of catarrhal appendicitis.
The attacks subside in six to eight hours, the
tenderness and meteorism become localized to the
ileocecal region, and the swollen appendix may
even be palpable. The patient may, however,
complain of pain in the ileocecal region upon
stooping or walking. The recognition of this
type of colic will be based chiefly on palpation
and the findings on rectal and vaginal examina-

PEHITONEAL ADHESIONS 73

tion. Such a colic may also occur in acute appen-
dicitis which results from a co-existing typhilo-
appendicitis. The cecum and ascending colon
will also be tender in these cases. Appendicitis
in children may produce only the above-described
colic without development of any other symp-
toms of appendicitis. The possibility of appen-
dical disease must be considered when we find
such a colic suddenly appearing during or imme-
diately after bodily motion or straining at stool.

When a patient complains of recurring, dif-
fuse, or vague colicky pains with constipation
or constipation alternating with diarrhea, we will
have to consider multiple peritoneal adhesions as
a possible cause. There may be complete ab-
sence of objective findings in these cases and an
assumptive diagnosis may be made on the per-
sistence of the symptoms in spite of all treatment.
The patients fear to eat because they believe that
the food will cause pain. As a rule, the diagnosis
will be made of chronic intestinal catarrh or even
of neurasthenia. The history of a previous dis-
ease capable of producing adhesions, the state-
ment by the patient that the pains appear rather
regularly on frequent stooping, walking, or run-
ning over an uneven surface, and the X-ray
examination will help in the diagnosis.

We must not forget that there are genuine
intestinal colics caused by spasm of the bowel
musculature, either in its entire length or only

ABDOMINAL PAIN

of certain segments. This may occur either in
the large or small intestine. The underlying
cause may be a central or local affection of the
nervous system, such as tabes, affections of the
vagus, chronic nicotinism, or a purely functional
disturbance. Tabetic crisis occasionally follows
periods of indigestion, but the typical attack
comes out of a clear sky without previous warn-
ing. Such an attack begins suddenly, may last
one or more days, and ends quite abruptly. The
gastric crises due to other diseases of the spinal
cord resemble that produced by tabes. The same
is true of crises produced by sudden irritation of
the posterior roots, as in anterior poliomyelitis,
acute myelitis, acute hematomyelia, and embolus
or thrombosis of the vessels of the spinal cord.

Similar crises may also be caused by diseases
of the abdominal aorta, Graves' disease, affec-
tions of the pancreas, and the neurosis which is
associated with an eosinophilia in the blood and
feces, and which may show a family eosinophilic
diathesis. These diatheses may be associated
with bronchial asthma, eczematous dermatosis,
intermittent swelling of the joints, and angio-
neurosis.

The diagnosis of such a nervous enterospasm
will be difficult, as the pains may become diffuse,
or the entire picture may resemble incomplete in-
testinal stenosis with constipation. Stiffening
and meteorism are, however, usually absent.

MUCOUS COLITIS 75

The feces in enterospasm may be ribbon-like,
divided in small particles, and covered with mu-
cus, while the bowels may move only between
long intervals of apparent constipation. The
spastic condition of the bowel may be recognized
by the effect of papaverine as seen under the
X-ray.

Mucous colitis may cause diffuse colic, and the
nervous patient may show symptoms which close-
ly resemble collapse. This form of colitis may be
only an accompanying symptom in lead poison-
ing or sclerosis of the intestinal vessels. The
intimate relation between mucous colitis and
bronchial asthma is well known {Neusser, Striim-
pell) . I remember a patient in whom the typical
attacks of bronchial asthma alternated with en-
terospastic colics either with or without mucous
colitis and eosinophilia in the feces. I consider
this enterospasm an expression of abdominal
vagotonia.

Such diffuse, abdominal pains may also be
the expression of an epileptic aura.

Extraabdominal conditions, such as pleurisy,
pneumonia, empyema, pneumothorax, and es-
pecially diaphragmatic pleurisy, may cause dif-
fuse abdominal pain with tension of the abdom-
inal walls, nausea, vomiting, and constipation.
These may be recognized in the early stage by
the discrepancy between the respiratory and
pulse rates and by the fact that the tenderness

rf tir tfKiTmtrm idi n lev marked on deep
jressKre tam at is cb s^crficial palpation. A
nfoSr dsvcisgn^ — nungilis may also cause

jm tuic with diar-

meningitis may be

5w x-7?iti» d the spinal roots either by

rnaiitr Acute affections of
abdominal walls only rarely

AakXter jgjrfcfapferagmatic condition which
awy >? i csase -£ wenkhepatic colic is subdia-
Mr$)CttCc Jx^Tixa zwtoris. especially in view of
»? face daa:; jo.vrrjsra: to AVatarr, a mild degree
ct icaertts :tfc* v iie H? present. Important in
tae r*c\.y?tifcct* „nf isas condition is the marked
jjfrftmg .^ xivecy* $ocaetfcing which occurs in
o&oifu:i^^< v*dy ex^pfcocAlhr. Another diag-
acstx jvtn: is tie difference between the sub-
><vciv^ sYtirvtvras and the absence of the usual
xtndis^s as seen in dbolelithiasi&. Furthermore,
the striking pallor and the effect of vasodilator
mediation will distinguish the disease.

Tetanv mav he associated with diffuse colic
either of the stomach or intestine. The history,
the iveurrence of the attacks chiefly in the spring
time, Trvmsstam's phenomenon, and the electrical
irritability of the motor nerves will help in the
diagnosis.

Another type of abdominal colic has been re-
cently described which is due to apoplexy of the

ADRENAL INSUFFICIENCY

adrenals. The clinical picture is not yet com-
pletely described but is, in short, intense colic,
which is repeated every few hours, slow, hard
pulse, occasional vomiting, a sense of impending
death, tension of the abdominal walls, no fever
and no visible stiffening or peristalsis. An ane-
mic, contracted loop of bowel has been seen on
laparotomy. Other cases show periodic apathy,
sweating, and a slow, irregular pulse. The pain-
ful attacks are so intense, that the patients may
cry out as in meningitis. Thirst, anorexia, and
vomiting may also be present.

Acute adrenal insufficiency may also cause dif-
fuse abdominal pains which are not always col-
icky in nature. This may occur during the
course of acute infections, narcosis or labor. It
may also result from chrome epinephritis, in
which cases the patients may complain of inter-
mittent, severe abdominal pains for a period of
years before a severe attack occurs. This sud-
den adrenal insufficiency may cause symptoms
which resemble acute or septic peritonitis. The
diagnosis may be made on the striking adynamia,
subnormal temperature, progressive fall of blood
pressure, vomiting, diarrhea, cerebral symptoms
(delirium, coma and meningitis-like symptoms),
and acute insufficiency of the circulation with
cyanosis. The abdomen will be soft and sunken,
and there is no rigidity. Rectal and vaginal
examination are negative.

ABDOMINAL PAIN

Mild, Diffuse, Colicky Pains

The first consideration must be given to the
simple intestinal colics. These last but a few
minutes, disappear or at least improve after pas-
sage of feces or flatus, application of heat to the
abdomen, massage, pressure, or assumption of
the crouched position. Such colics may be due
to intestinal parasites and are usually associated
with headache, nausea, dyspepsia, and excessive
hunger. Such mild colics may also be caused by
infectious diseases in which the intestines are par-
ticularly involved, as in paratyphoid, dysentery,
cholera, anthrax, typhoid, and Malta fever.

Such mild attacks of colic may also be caused
by mild appendical disease. Mild appendicitis
may not produce any real pain but only chronic
dyspeptic complaints, some meteorism, irregular
bowel movements, and a vague, colic-like feeling,
brought on by indiscretions in diet. Of im-
portance are local tenderness over McBurney'g
point, local hyperesthesia of the skin, and deter-
mination by the X-ray that the point of tender-
ness corresponds to the appendix. Peritoneal
adhesions cause pains on stooping and during
defecation or urination. Vomiting, nausea, eruc-
tations, and sudden stoppage of feces and flatus
may also be seen in some cases.

PERITONITIS (Tt'BEHCCLOUS) 79

Mild, Diffuse, Abdominal Pain not Colicky
tn Nature

We must not forget that, occasionally, acute
peritonitis or chronic tuberculous peritonitis, and
especially pneumococcic peritonitis may produce
this type of pain and not that which is usually
present in these cases. The latter form of peri-
tonitis will often produce herpes and dominished
chlorides in the urine.

Acute miliary tuberculosis of the peritoneum
must be considered if pains and free fluid appear
in the abdomen during the course of a case of
known miliary tuberculosis. In some rare cases,
the abdominal symptoms may be the most con-
spicuous, and the diagnosis will be strongly sup-
ported by finding a hemorrhagic fluid with a
predominant lymphocyte count, even though the
course is acute. Other foci of tuberculosis may
be found in the pleura, pericardium, or synovial
membranes of the joints. We must remember
that tuberculous peritonitis may begin with pain-
ful flatulence.

Diffuse carcinomatous peritonitis rarely pro-
duces pain. This condition is differentiated from
tuberculous peritonitis by marked edema of the
skin of the abdomen and absence of anasarca ; the
urine is pale, and tbe peritoneal fluid is hem-
orrhagic. The finding of tumor masses and fluid
in the abdomen at tbe same time speaks for car-

80 ABDOMINAL PAIN

cinomatous peritonitis, as the fluid in tuberculous
peritonitis disappears when the tumor masses
develop. Cytological examination of the fluid in
these eases is not of any differential value, and
the same is true of a positive Diazo reaction or
fever. Localized peritonitis, such as occurs in
periappendicitis or perisigmoiditis as well as in
affections of the intestines may all begin with
such diffuse pains which later become localized.
Pancreatic affections of mild degree or func-
tional nature may also lead to such pains, but,
as a rule, these tend to remain localized in the
epigastrium.

The muscles of the abdominal walls, especially
after prolonged contraction, may also cause such
pains. The other muscles will, however, also be
affected. The abdominal muscles alone may be
affected in tetany in cases of gastric dilatation.
Muscular pains may also be caused by prolonged
and severe coughing, singultus, dyspnea or pro-
longed vomiting.

The ordinary rheumatic myalgias are charac-
terized by the fact that the pains are usually
diffuse and shift in location. There is no fever,
and the pain is increased by muscular movements
such as during coughing, sneezing, getting up,
or walking. The pains regress or disappear when
the patient is quiet, and reappear when he moves
about. Sudden pressure increases the pains, while
pressure, when gradually applied and increased,

MYALGIA — TRICHINOSIS

does not make them more severe. The pains
are sometimes localized at the tendinous inser-
tions of the muscles. Food or digestion has no
effect, while the influence of weather, local heat,
and aspirin is well known. Muscular pain may
be very severe in the infectious diseases in which
there is degeneration of the muscle.

Hemorrhage into the degenerated muscle in
typhoid fever may even simulate intestinal per-
foration, but is distinguished by the fact that
the tenderness is greatly increased when the mus-
cle is contracted as in sitting up, while applica-
tion of pressure during this act does not produce
an increase of the pain in intraabdominal disease.

Trichinosis of the muscles may cause such
pains as well as nausea, vomiting, and diarrhea.
The pains may be due to the presence of tri-
china? or to the enteritis. The diagnosis will be
made on the presence of tenderness in other
muscles, the pseudotyphoid course, sweating,
edema of the skin, especially of the eyelids, eosin-
ophilia, the history, and, finally, the histological
examination of a piece of excised muscle.

The subcutaneous tissue may also be the seat
of such pain. This may be the case where there
is a rapid loss or gain in weight. The pain may
be in the epigastrium in these cases. Adipositas
dolorosa may be another cause and is recognized
by finding painful, fat nodules, bluish-red color
and increased consistency of the skin, and by the

82 ABDOMINAL FAIN

distribution of the disease on the extensor sur-
faces of the deltoid, humerus, and legs.

Such pains in the abdomen may also be found
in acromegaly and are due to the increase in
size of the abdominal organs.

Finally, we must remember that affections of
the seventh and eighth intercostal nerves may
cause pain in the abdomen. This may be due
to a primary neuritis, disease of the spinal cord,
or irritation from the pleura. The diagnostic
features are the pressure points along the nerves,
the sensory disturbances, and the effect of in-
jections as of pyramidon at the site of pain.
Superficial touch will be more painful than deep
pressure, and the navel will be displaced by the
spasm of the muscle.

Chronic, Diffuse Abdominal Pains

We must keep in mind all the types of chronic
peritonitis, such as neoplastic, tuberculous, syph-
ilitic, chronic adhesive, and that resulting from
changes in the peritoneum caused by a previous
acute peritonitis. All these may remain dormant
for a long time and may not produce demon-
strable tumors or fluid. This is especially true
in the syphilitic and chronic adhesive types.
Chronic, diffuse pains may also be produced by
localized processes such as periappendicitis or
pericholecystitis. Finally, we must remember
the neuroses which are especially common dur-
ing the climacterium.

Localized Abdominal Pain

Before discussing abdominal pain and its lo-
calization, I wish to emphasize a few general
important points. The first is that we must
keep in mind the possibility of a dystopic organ,
that is, an organ not in its normal place. Ileoce-
cal pains, for instance, may be produced by a
wandering kidney or spleen, low pylorus, long
sigmoid flexure, or long jejunal loops. Again,
pains in the gallbladder region may be due to
an upward dislocation of the right ovary or
even uterus when it is drawn up to this region.
The appendix, in particular, merits discussion
as an organ capable of assuming any location in
the abdomen. It may be located in the gall-
bladder region when the cecum has not de-
scended to its normal location, it may be on the
left side in cases of inverse position of the ab-
dominal organs, or the appendix itself may be
in its normal location, but with the tip outside of
this area as a result of adhesion. The pains in
appendicitis may be located anywhere in the ab-
domen, and operation may reveal the abnormal
location of this part of the bowel. In addition
to the usual symptoms in these cases of disloca-

84 ABDOMINAL PAIN

tion, we have a very important finding in the ap-
pearance of pain over the normal appendix area
when we press over the displaced appendix
wherever it may happen to be, while pressure
over the ileocecal region may cause pain in the
displaced appendix.

The second point is that a tuberculous peri-
tonitis may begin or subsequently localize in any
part of the abdomen.

A third point is that pains and other perito-
nitic symptoms, such as meteorism, rigidity, dull-
ness, and evidences of a localized exudate, which
shift from place to place, may be manifestations
of a progressive fibrino-purulent peritonitis.
Other conditions which may cause such a picture
are the spreading of a local peritonitis or a tu-
berculosis of the intestines leading to tuberculous
or purulent peritonitis.

als

Epigastralgia or Stomach Cramps

Colicky Epigastralgia

When a patient complains of colicky pains in
the epigastrium, I usually adhere to the follow-
ing principle: in middle-aged male patients and
young girls up to the age of puberty, I first sus-
pect the appendix; in women past the age of
puberty, especially during middle age, I suspect
liver colic, that is, cholecystitis or cholelithiasis,
especially if gynecological disease can be ruled
out.

Epigastric pain occurs especially during the
•st or second day in appendicitis. These pains
so occur very early in mild cases of gallstones
and may come in attacks over a long period of
time in the chronic cases. Appendicular colic
must also be considered when the epigastric
pains are colicky in nature.

Appendicitis has already been described on
pages 72, etc., etc. Briefly stated, it may cause
colicky epigastralgia, reflex vomiting, occasion-
ally symptoms of collapse and spontaneous dis-
appearance of the pain in a few hours even with-
out medical aid. The attacks may recur either

AHDOMINAL PAIN

without apparent reason or they may follow die-
tetic errors, brisk motion, chilling of the body,
constipation, diarrhea, or migration of parasites
into the appendix. The diagnosis will be made
on the location of the chief point of tenderness
under McBurney's point, pressure in the epigas-
trium will cause pain in the ileocecal region,
while pressure over the latter area may provoke
pain in the epigastrium. There are hyperes-
thesia of the skin over the ileocecal region, ab-
sence of the abdominal reflexes in the right lower
abdomen, Kustner's sign, that is, absence of
bulging of the ileocecal region during inspira-
tion, and Blumberg's sign, which consists of an
increase of pain upon suddenly releasing the
hand after deep pressure has been applied over
the appendix. Occasionally, the tender appen-
dix may be palpable.

Similar objective findings are found in acute
appendicitis, that is, endoappendicitis. The ten-
derness will be limited to the appendix in this
condition, while the surrounding parts will not
be tender even on deep pressure. The appen-
dix itself may be palpable as a finger-like tu-
mor, which is smooth and which may or may not
be movable. Vomiting and fever may be pres-
ent for a few days. As a rule, we find consti-
pation, while diarrhea is rare and when present
usually appearing before the attack. Upon care-
ful questioning, we learn that the pain is continu-

PERIAPPENDICITIS

ous, but there may be remissions, and it is often
described by the patients as stomach cramps.

The palpable tumor mass in acute periappen-
dicitis may be due to perforation, migration of
bacteria through the appendix wall, causing in-
flammation, and exudate. The mass is smooth,
fixed, and cylindrical in shape, and it sometimes
fills out the entire lower right quadrant of the
abdomen. The mass may also be caused by the
edema, feces in the cecum, or adherent omentum
or intestinal loops. At times we may feel a
vague, tender resistance instead of a definite
mass. Of great importance is the sequence in
which the symptoms develop. The disease be-
gins with a continuous pain, followed shortly by
nausea or vomiting and in a few hours by fever.
The pulse rate is increased, and sometimes we
observe chills with the onset of fever.

The objective findings are similar to those in
appendicular colic plus the finding of the pal-
pable tumor mass and the other findings usually
present in appendicitis. The pains may some-
times radiate to the right lower extremity and
occasionally to the testicle. Vaginal and rectal
examinations are important. These examinations
will sometimes show tenderness in the ileocecal
region, and the tender tip of the appendix may
occasionally be palpated. The navel and linea
alba may be drawn to the right, the vena circum-
flexa ileai may be dilated, and pain may be pro-

duced by performing the Kernig test. Sometimes
the patients keep the right thigh in flexion, either
to loosen the muscle tension or perhaps as a re-
sult of a spasm of the psoas. The patients stoop
forward when walking for the same reason. The
patient is unable to remain on his left side.
Pain may sometimes be produced in the ileoce-
cal region by pressing upward along the descend-
ing and transverse colon without touching the
ileocecal region. Pain in the appendical region
may also be elicited by traction on the right sper-
matic cord. There may be pain during urina-
tion and before or after defecation. Tenderness
will be present on percussion of the abdomen.

Such stomach cramps may be observed in
chronic as well as in acute cases of appendicitis.
This is especially likely to occur in chronic ad-
hesive appendicitis or even where no evident
pathology exists except an abnormally long ap-
pendix or one with a very short mesenteriolum.
The diagnosis will be supported if we can pal-
pate the appendix. In this connection, I wish to
adhere to the principle of Hausmann, who states
that we must palpate the last part of the con-
tracted ileum at the same time that we feel the
appendix, in order not to mistake the former for
the latter.

Adhesions about the appendix need not be due
to diseases of this organ but may be secondary
to disease of the female genitalia, cholecystitis

or pei

GALLBLADDER DISEASE

or pericholecystitis, perigastritis, periduodenitis,
pericystitis, trauma, or polyserositis chronica.

There are diseases of the ileocecal region other
than appendicitis which may cause epigastric
pains with radiation of the shoulder so that the
picture may resemble that of cholecystitis. Such
conditions are the various stenoses of the intes-
tine or cecum, but these cases will also show
many gurgling sounds which arise from the in-
testine. Other diseases are cecum mobile and
tuberculosis of the ileocecal region. The latter
may closely resemble gastric ulcer if the pains
appear about five hours after meals and radiate
behind both costal arches.

There are two conditions causing epigastric
pains in which the diagnosis can hardly be made.
These are volvulus of the appendix and torsion
of the appendicas epiploicfe.

In a previous paragraph, I have already stated
that severe abdominal pain in women must
awaken the suspicion of a possible gallbladder
affection. The pains may vary greatly in se-
verity and duration. We must also remember
that such pains may be due to actual reflex py-
lorospasm or gastrospasm conditions which are
often associated with disease of the gallbladder.
The pyloric spasm may occasionally be palpated,
and the gastrospasm and pylorospasm may be
detected by the X-rays.

Gallbladder disease may be suspected when

ABDOMINAL PAIN

the pains occur at the same time after meals, and
when the most frequent period is during the
night.

Such nocturnal pains are almost character-
istic for gallbladder trouble, but cannot be con-
sidered as pathognomonic, as we know that pain
at this time may also be caused by ulcer of
the stomach or duodenum as well as in chronic
or recurrent appendicitis. More important for
the diagnosis of gallbladder disease is the fact
that the pain begins very suddenly, is often ac-
companied by a chill, and quickly reaches its
maximum severity. The pain radiates to the
right costal arch and to the right side of the chest,
behind the sternum, but especially to the re-
gion of the posterior part of the liver and right
shoulder-blade. The epigastrium may bulge for-
ward, and it is characteristic that the vomiting,
if it occurs at all, does not entirely relieve the
pain. The pain tends to disappear rather ab-
ruptly, even if its onset was gradual. The se-
verity of the pain prevents deep breathing, the
skin over the liver is hyperesthetic, and the same
is true over the region of the gallbladder and
posteriorly between the tenth and twelfth ribs
on the right side. The patient cannot remain on
his left side, and he sometimes complains of diz-
ziness during the attack. Reflex rigidity of the
right upper rectus is very important, as are ten-
derness on pressure or percussion in the region

of the incisura hepatica, especially if we palpate
upwards rather deeply during inspiration. Ten-
derness on pressure or percussion may sometimes
be found in the midline or even to the left of it,
and may thus resemble gastric disease. Pres-
sure over the gallbladder may sometimes cause
pain in the epigastrium. When the fains are
far to the left of the usual location, we may be
dealing with stenosis of the common duct.

Enlargement of the liver and a perihepatic
rub may sometimes be found. Mild cases may
not show any tenderness, enlargement of the
gallbladder or even fever. Chilly sensations or
chills may, however, be present. Icterus is ab-
sent in the majority of cases of gallbladder dis-
ease, but urobilin and urobilinogen are usually
present in the urine. Icterus occurs only when
there is a stone or inflammation of the mucosa
of the common duct. The inflammation may
extend from the hepatitis or from the chole-
cystitis to the common duct.

Not uncommonly we find that gallbladder
disease and appendiceal affection exist together
at the same time. This may be due to a spread
from one to the other by hematogenous or lym-
phatic routes or by peritoneal adhesions extend-
ing from one to the other. If the adhesions
from cholecystitis involve the duodenum or py-
lorus, then we may observe a combination of
symptoms arising from the causative trouble

ABDOMINAL PAIN

plus the signs of stenosis of the stomach outlet.
We must also consider the possibility of a simul-
taneous, hematogenous infection of the gall-
bladder and appendix from some other source.

The diagnosis of adhesions will be based on
the colicky nature of the pains without enlarge-
ment of the gallbladder, absence of a perihe-
patic rub, a history of previous attacks of colic,
appendicitis, disease of the female genitalia, or
of operation on the gallbladder with reappear-
ance of the pains.

Disease of the stomach, anatomic, secretory,
or neurotic, may be considered after disease of
the gallbladder and appendix have been ex-
cluded. A genuine nervous gastralgia is one of
the greatest of rarities, and I avoid this diag-
nosis as much as possible.

We may consider neurotic gastralgia if the
pain is neither increased nor decreased by local
pressure or when it is lessened by galvaniza-
tion. There may be marked tenderness upon
light pressure over the cceliac plexus. The
pains in these cases are very capricious and
easily influenced by psychical states, food may
not at all alter the pains, and sometimes the
patients state that they can now eat certain
foods which they could not previously bear.
The patients do not experience difficulties with
indigestible foods and may complain after eat-
ing a very light meal. The fact that the pain

SECONDARY GA8TBALGIA

appears almost immediately after meals is sug-
gestive, but this occasionally occurs in gastric
ulcer. Finally, we sometimes observe that the
patients get an abnormal sense of thirst and
hunger immediately after an attack. Polyuria
and frequent urination may occur in anatomic
as well as in functional disease of the stomach or
even in disease of other organs.

More frequent than the genuine primary gas*
tralgias are the secondary gastmlgias resulting
from disturbances in the female genitalia, as in
cases of menstrual gastralgias, even if the fe-
male genitalia are anatomically normal. Ana-
tomical lesions causing gastralgia are those oc-
curring in the ovaries, uterus, or tubes. Both
the gastralgia and the disturbance in the fe-
male genitalia may be caused by a disease of
the nervous system or by abnormal position of
the female genital organs. Sexual neurosis in
men may also be responsible for pains in the
epigastrium. Other causes of secondary epi-
gastralgia are disease of any of the abdominal
organs, the presence of intestinal parasites, dis-
ease of the central nervous system (tabes), in-
toxications, as nicotinism, and infections, as
malaria.

We shall now discuss the organic affections
of the stomach. A simple acute indigestion
may lead to such a stomach cramp when caused
by food that is too hot or mechanically too ir-

94 ABDOMINAL PAIN

ritating to the stomach, very spicy or gas-pro-
ducing; by coffee, or by too rapid eating.
Such pains will last a comparatively short time
and are relieved by deep pressure, crouching
posture, or local application of warmth to the
abdomen. We must remember that such indi-
gestion cramps will appear much more readily
in a stomach which is already diseased, as by
gastric ulcer, etc

The gastric ulcer is one of the most frequent
causes of stomach cramp and is due to pyloro-
spasnu gastrospasm, or, if the ulcer is located
high up* to cardiospasm* Such a cramp fol-
lowing acute indigestion, trauma, or "cold" may
be the first sign of gastric ulcer. It may occur
for weeks or months, while the patient is free
from any discomfort during the intervals. By
and by the intervals become shorter, and the
attacks sometimes occur at night. We may ex-
plain this nocturnal appearance by remember-
ing that the food residue which remains in the
stomach overnight sets up an irritation which
is followed by a pylorospasm, or, perhaps, di-
rect irritation of the ulcer area. We must also
consider genuine "wound pains" caused by irri-
tation of the sensory nerves at the base of the
ulcer. This pain is sharply localized, and the
tenderness on pressure or percussion is sharply
circumscribed. The localization to the left of
the midline is not alone associated with ulcer,

WOUND PAINS 9o

as it may- also occur in carcinoma or neurosis.
The tenderness is increased by deep pressure,
the skin of the epigastrium is hyperesthetic, the
tender point of Boas is present in the back, and
the X-ray will show a "Nische" at the site of the
ulcer with a spastic indrawing of the opposite
side. In addition, there are two important find-
ings, the occult bleeding in the stool and the
hyperacidity. The history will complete the
picture when the patient states that the severity
of the pain depends on the nature and time of
meals, and that the pain often disappears after
a milk diet. The pain radiates especially to the
left side of the trunk, going backwards like a
bridge from the epigastrium to the spine or
even to the shoulder-blades. The pains may be
so severe that the patients are afraid to eat.
There are also eructations and vomiting of acid
contents.

We must remember that there are cases in
which the history resembles that of a nervous
affection. These patients digest heavy food
and experience pains, especially after psychical
excitement.

Typical cases will cause no difficulty in diag-
nosis, but we must not overlook the fact that
there are ulcer cases, proved at operation, which
have shown subacidity or even anacidity. There
are also cases in which there is little or no pain
and in which the first sign of serious trouble is

ABDOMINAL PAIN

hematemesis or perforation. There are cases
in which the pain does not depend on the food
intake, but occurs on bodily motion or adoption
of a certain position. The pain in the latter
group may be explained by a pulling on the ad-
hesions or by the fact that the acid stomach
contents are in contact with the ulcer surface
only when the patient is in a certain position.

Similar pains may, of course, be caused by
ulcers of various types, such as tuberculous or
syphilitic lesions.

Patients with ulcus callosum penetrans are
often anemic and cachectic, like those suffering
from carcinoma, and this may cause confusion
when a tumor mass is palpable on the left side.
The chronic nature and the periodicity are char-
acteristic, but the attacks themselves may vary
in intensity. The pain does not often radiate
to the back and hyperacidity need not be pres-
ent, but the condition is differentiated from car-
cinoma by the X-ray, bacteriological, and chem-
ical examination of the stomach contents.

The symptomatology of the chronic gastric
erosion closely resembles that of the peptic
ulcer. We know that such hemorrhagic ero-
sions follow such affections as chronic gastric
catarrh and affections of the blood vessels of
the stomach (amyloidosis, arteriosclerosis, luetic
endarteritis, thrombosis, and emboli). We also
find them in the acute infections and nephritis.

. ULCUS CALLOSUM PENETRANS

I We must, perhaps, consider these erosions as an
early stage of ulcer. Above all, the diagnosis
is established by the fact that the acute malena
and sensation of weakness disappear after a
milk diet of a few days to a week. I lay great
stress on the finding of needle-point, blood-
tinged particles in the stomach contents, which
appear like collections of cells on microscopical
examination, assuming the shape of the gastric
glands. These erosions are a part of the affec-
tion known as gastritis exfoliativa. Macroscopic
hematemesis is absent, and we sometimes find
a subacidity or absence of acid. The pain may
be very severe and appear early after meals
(one-half hour) and disappear in about two
hours, depending on the nature of the food.
The pain is not cramp-like but gnawing in char-
acter and is diffuse in distribution. It does not
radiate, and there is no hyperesthesia of the
skin.

Just as gastric ulcer leads to a pylorospasm
which is due to a hyperacidity, so may hyper-
acidity alone cause pyloric spasm with a sensa-
tion of heaviness, pains, and burning in the epi-
gastrium after meals. We will find that certain
foods, especially starchy foods, will more read-
ily cause these epigastric pains. Fats, albumin,
alkalies, or dilute foods like milk or beer will
diminish the pains. There are also heartburn,
acid eructations, and occasionally vomiting of

98 ABDOMINAL PAIN

very acid contents, with relief of the symptoms.
Nocturnal pains appear only if the patients eat
abnormally rich or indigestible food in the eve-
ning. Hyperacidity rarely occurs as a func-
tional, secretory disturbance of idiopathic origin.
It is more often a symptomatic finding result-
ing from an anatomical, gastric, or extragastric
disease. The diagnosis is made on the finding
of hyperacid stomach contents and an alkaline
urine. The objective findings may be very mild
or diffuse, with indistinct tenderness in the epi-
gastrium, especially in the pyloric region.

Another condition which may cause identical
symptoms is hypersecretion, of which we recog-
nize three types — the continuous, the intermit-
tent, and the digestive. We will suspect this
condition when we obtain a strikingly large
amount of fluid on aspiration of the stomach
contents, with food rests which are well digested
and HCL values of variable degrees. The safest
method to determine this condition is to give a
dry test meal consisting of five very small bis-
cuits and to aspirate in from one-half to three-
quarters of an hour. In hypersecretion, the con-
tents obtained after this dry meal will contain
an abnormal amount of acid fluid.

A digestic hypersecretion may be a reflex
neurosis in cases of nervous dyspepsia, especially
when combined with enteroptosis or atony of the
gastrointestinal tract. It is also a common find-

ing in
appeni

HYPERSECRETION

ing in gastric ulcer, acid gastritis, cholelithiasis,
appendicitis, hernia of the linea alba, and cases
of chronic nicotinism.

The intermittent type of hypersecretion will
have to be considered when we obtain a history
of repeated attacks of sudden, cramp-like pains
either during the night or more commonly in the
morning, followed by vomiting of bile-stained
residue of food which was eaten during the
previous evening, and, later, with vomiting of
strikingly large amounts of fluid. Such an at-
tack may last several hours or days. We will
find a large quantity of acid, sometimes hyper-
acid fluid contents, on aspiration during the at-
tack, either during a test meal or from an empty
stomach. Such an intermittent hypersecretion
may be purely functional and may be caused by
psychical emotions, or chronic nicotinism. It
may occur in the gastric crises of tabes and
cause the pain instead of the usual nervous fac-
tor. Furthermore, we know that it occurs in
migraine, cerebral affection, and Basedow's dis-
ease.

More common than the intermittent type is
the continuous hypersecretion. Only a few au-
thors consider it as idiopathic in origin. I am
in accord with those who consider it as a symp-
tomatic disease, resulting from ulcer, chronic
nicotinism, or benign pyloric stenosis; less often
resulting from extragastric conditions, such as

100

ABDOMINAL PAIN

duodenal ulcer, periduodenitis, chronic obstipa-
tion, intestinal parasites, especially tenia, and
tabetic crises; found occasionally in cases of
chronic icterus following biliary cirrhosis or ob-
struction of the bile ducts. It may also be due
to simple chronic gastritis with pylorospasm.
Continuous hypersecretion is very rarely found
in carcinoma or sarcoma of the stomach.

The history of this symptom is very charac-
teristic. The patients not only complain of pain
after meals, but also of a burning or feel-
ing of pressure even when the stomach is empty,
especially at night or early in the morning.
The feeling is relieved by fat or albumin and
is followed by vomiting of a large amount
of fluid. The contents may be distinctly three-
layered, the upper foamy layer, containing
gas bubbles, the middle fluid layer, which is
the one that is so copious, and the sediment.
The hypersecretion itself is continuous, but the
subjective symptoms may be intermittent, and
this is shown by the fact that we can obtain
hypersecretion contents from the stomach dur-
ing the apparently normal intervals. Hyperse-
cretion may also be recognized by X-ray upon
seeing a large quantity of fluid in the stomach
after giving the bismuth mixture as a gruel or
pudding and also by the two-capsule method.

Achylia, the opposite of hypersecretion, may
cause similar symptoms. I wish to warn against

CHRONIC GASTRITIS 101

making a diagnosis after only a single aspira-
tion, as the psychical influence may change the
chemical aspects of the gastric secretion and give
a wrong picture.

Disturbances in the secretion of gastric mu-
cus may cause similar symptoms. These may be
amyxorrhea (absence of mucus) or gastromyx-
orrhea (hyperproduction of mucus). The for-
mer is extremely rare; it may show normal or
low acidity, the stomach contents are easily fil-
terable, and the food particles show no tendency
to clump or to adhere. The increase in the mu-
cous secretion in the second condition may be
continuous and, as a rule, without subjective
complaints. It may also be of an intermittent
type, resembling or even replacing an attack of
gastric crisis in tabes. The fasting stomach
shows a mucous content of more than 25 c.c.

Chronic gastritis sometimes leads to attacks
of cramp-like pains, especially after coarse or
heavy meals. This may be a result of the
achylia or acid gastritis. Sometimes the abnor-
mal condition of the gastric mucosa may be the
causative factor. In earcinoma of the stomach
and other atrophic gastrites, we find a special
type of intermittent pains in which the patients
state that their stomach is rapidly turning
around, and these are followed by the welling
up in the mouth of a watery fluid.

Cramp-like pains in the epigastrium may be

102 ABDOMINAL PAIN

a sign of pyloric stenosis. The stenosis may be
due to a compression of the pylorus from with-
out, changes in the wall itself, or obstruction
from within. The picture may very much re-
semble gallbladder colic. The pains may appear
two to three hours after meals, sometimes also
at midnight, and may radiate to the right shoul-
der. The diagnosis will be made on finding re-
tention or stagnation of food, retention vomiting
of putrid contents, and stiffening or peristalsis
of the filled stomach. Sometimes there is a feel-
ing as though the pains are being pulled from
left to right. In atypical cases, the pains may
remain in the left or right epigastrium or even
on the midline and radiate to the left shoulder-
blade or travel girdle-like to the left.

I wish especially to point out those cases in
which there is no previous complaint, but which
suddenly show a stomach cramp and which are,
in reality, a relative stenosis which has existed for
some time but which now manifests itself by dila-
tation of the stomach and stagnation of its con-
tents, especially after a rich meal. After vomit-
ing of the contents, the patient may be relieved
and present no symptoms for several weeks or
even a month, until a similar attack again ap-
pears, so that we see the picture of an inter-
mittent pyloric stenosis. Sometimes, however,
the condition is not relieved, and surgical inter-

PYLORIC STENOSIS

rference must be instituted, as, for instance, in
cases of gastric tetany.
Among the acquired types of pyloric stenosis
in adults we must point out one type which
comes on at middle age. It is called stenosing
pyloric hypertrophy, stenosing gastritis, or hy-
pertrophic pyloric stenosis. It is not yet known
if the hypertrophic gastritis is the only factor
causing the stenosis or whether we are dealing
with a congenital defect which has remained
latent. The picture resembles that of a stenosis
by a gastric ulcer. As a rule, we find sub- or
anacidity, and at times occult malena. Symp-
toms of stenosis are variable, and intermittent
and a pyloric tumor is not an uncommon find-
ing. There is, also, a real congenital type
which produces a stenosis in early infancy. In
these cases pains (pylorospasm) are rather ex-
ceptional.

Not only pyloric stenosis, but stenosis in the
body of the stomach {hourglass stomach) may
show the symptoms of gastric ulcer as before
described, and it makes no clinical difference
whether the condition is anatomical or functional
in origin. X-ray findings are of more value in
the diagnosis of this condition than are the
physical signs.

Furthermore, the genuine acute dilatation
of the stomach may produce violent somach
cramps early in the onset and may last for sev-

104

ABDOMINAL PAIN

eral hours. Such acute dilatation may occur
after operations on the abdomen, prolonged nar-
cosis, severe and exhausting diseases, overload-
ing of the stomach, and acute arteriomesenteric
obstruction.

I wish to mention two other causes, bleeding
into the stomach, especially if the stomach has
previously had an abnormal shape, such as
after scar contraction and compression neu-
ritis of the left splanchnic nerve, which may be
caused by pressure from a tuberculous mass.
The acute dilatation may be diagnosed by ob-
serving the prominently dilated stomach in an
otherwise concave abdomen, enlarged area of
tympany on percussion, ability to produce
splashing sounds all over the stomach, high po-
sition of the left diaphragm and heart, severe
vomiting which may be continuous and gushing,
no disturbance in the passage of feces and
flatus, unquenchable thirst, shock, and absence
of abdominal rigidity. The findings on aspira-
tion or X-ray will help to confirm the diagnosis
as well as the fact that the symptoms sometimes
regress on assuming the knee-elbow position or
lying on the right side. Vomiting will, of course,
be absent if the stomach is empty, as in cases
after narcosis. In such cases there is a striking
enlargement of the area of gastric tympany and
an escape of air on using the stomach tube.

Kinking of the pyloric or duodenal region

GASTKOPTOSIS 105

may occur in cases of gastric or duodenal ptosis
and in acute overloading of the stomach. There
are epigastric pains which radiate to the back
and may even resemble acute pyloric obstruc-
tion, but the differentiation will be made with
the X-ray. A gastroptosis, even without kink-
ing, may produce such epigastric pains to the
left of the midline. The mere finding of a gas-
troptosis of itself does not justify the assump-
tion that the symptoms are due to this finding,
unless we can rule out such organic lesions as
ulcer, carcinoma, cholelithiasis, etc. In addition,
we find the typical symptoms of ptosis such as
a sensation of fullness or heaviness in the epi-
gastrium before the real pains begin. These ap-
pear periodically after meals and are worse in
the upright position or when the patient is walk-
ing downstairs, and are relieved by raising the
stomach either by a bandage or with the hands.
The pain depends rather on the quantity than
on the quality of the food; small portions of
poorly digestible foods will be well borne, while
large quantities, even of milk, will produce this
pain.

As previously mentioned, pylorospasm may
produce cramp-like pains. This spasm may be
caused by the various anatomical and functional
lesions of the stomach and by extragastric le-
sions such as appendicitis, cholecystitis, duo-
denal ulcer, spastic constipation, intestinal para-

106

ABDOMINAL PAIN

sites, diseases of the central nervous system, as
tabes and intoxications, as chronic nicotinism, or
it may be purely the result of a functional dis-
turbance. The clinical findings in these cases
are pains radiating from the epigastrium to the
right, appearing rather late after meals (two to
five hours), or perhaps without any relation to
food at all. It may appear at intervals of sev-
eral weeks and later at more frequent inter-
vals. They are relieved by food, soda, and local
heat; vomiting may be present, and peristalsis
and stiffening may also be seen. Hypersecre-
tion and stagnation may be absent for a long
time or remain entirely latent. The spastic,
contracted pyloric ring may, at times, be pal-
pated, and the diagnosis will be supported by
the use of X-rays after and before the use of
papaverine.

In regard to neoplasms of the stomach, we
must mention the fact that cramp-like pains may
appear before symptoms of pylorospasm occur.
Marked pains, in my opinion, point rather to a
sarcoma than to a carcinoma of the stomach if
the general picture of carcinomatous disease of
the stomach does not fit the case very closely.

The description of the pains in ulcer applies
just as well to cicatrized or nearly cicatrized
cases of ulcer, except that the acute bleeding
from the gastrointestinal tract will be absent.
The differentiation of scar conditions from peri-

gastritis of any origin will be very difficult. In
favor of adhesions are the X-ray findings, a
palpable tumor which is caused by the ad-
hesions, the presence of a fibrous pleurisy, peri-
carditis, mediastinitis, peritonitis, local trauma,
or diseases of the stomach or other organs which
may cause adhesions. The pains are pulling
rather than cramp-like in nature, depend more
on the quantity than on the quality of the food,
and bear a close relation to certain movements
or positions of the body. Local tenderness on
percussion or palpation is absent or indefinite,
and malena is absent. The pains in adhesions
are sometimes rather capricious, and may, there-
fore, be mistaken for those due to a neurosis.

The perigastritis may be purulent as well as
adhesive. The former condition produces cramp-
like pains after meals, and there may be a
tumor of about the size of an apple, which may
be mistaken for carcinoma. The tumor will,
however, show a striking tenderness on palpa-
tion, and there will be fever.

The diagnosis of benign tumors of the stom-
ach, such as polypus, may be made only when
we obtain pieces of the tumor tissue on aspira-
tion of the contents of the stomach. These tu-
mors produce crampy pains, but no characteris-
tic symptoms.

There is another condition which may produce
cramp-like pains. The pain is not so severe and

108

ABDOMINAL PAIN

feels rather like a pressure or sensation of tight-
ness, such as is felt in the distention due to gas-
tric meteorism. We see this condition in the
decomposition of food with gas production in
organic stenosis of the pylorus. The patient
complains of a sensation of anxiety, faintness,
palpitation, chilliness, and sweating. This con-
dition lasts until the gas finds its way out either
through the cardia or pylorus. Aspiration pro-
duces immediate relief with the escape of
stinking gas. Such a pneumatosis of the stoi
ach may be purely functional, as in air swal-
lowers. The pains may hinder respirations, are
located in the epigastrium, may radiate to the
back or both flanks, and disappear after passage
of gas. No spasm of the pylorus seems to be
present in many cases; instead, we find a spasm
of the cardia or middle part of the stomach.

Temporary cramp - like stomach pain must
also remind us of the possibility of involvement
of the blood vessels in this region and especially
of arteriosclerosis of the arteries of the stomach
or of the abdominal aorta, with narrowing or
traction of the branches of the latter at their
origin as well as aneurism of the abdominal
aorta or its branches. The pains may be press-
ing, burning, or tearing in nature, and may
last but a few minutes. Sometimes there ap-
pears to be a relation to meals, as the pains
appear one-half to one hour after eating, es-

m-
al-

peciall

ARTEKIOSCLEHOSIS

109

pecially when the food is of a gas-producing
nature. Nausea may be present, but vomiting
is rare. In some cases, however, there is no re-
lation to meals, and the pains may appear at
any time of the night or day. The pains may
also appear at intervals of weeks or months,
as in gastric ulcer, and even hematemesis may
occur, which is a result of sclerosis of the vessels
or erosions which are caused by the narrowing
of the vessels. Some cases resemble carcinoma
with the anorexia, loss of weight, and even ca-
chexia. Anacidity may also be present.

The fact that we find sclerosis in other places,
dilatation and hypertrophy of the left heart,
increased blood pressure, and evidence of scle-
rosis of the abdominal aorta will be of a certain
value, but, of course, these signs are not decisive,
as they may be concomitant conditions which
exist along with a gastric ulcer or carcinoma.
More important for the diagnosis is the fact
that there was a period of flatulence and meteor-
ism for weeks or months before the onset of
the painful period. During this pre-painful
period, the patient feels distended after meals
and feels relief after belching. Of the greatest
value in the diagnosis is the fact that the pains
appear not only after food, but also after quick
or strenuous motion, sometimes even after an
after-dinner walk. These pains are relieved
when the patient lies down. Furthermore, we

110 ABDOMINAL PAIN

limy consider the therapeutic effect of diuretin
or theobromine. Hyperacidity as well as hyper-
secretion point against arteriosclerosis of the

vessel**

Very similar attacks occur in chronic nicotin-
ism ami are partly a result of a vasoconstriction.
The pains in chronic nicotinism may radiate to
the chest or hack* diarrhea and frequent desire
fv*r a bowel movement may be present. The
attack may end with a cough, the so-called
stomach cough. I wish to point out that the
limst injurious form of tobacco use in this sense
is chewing, less so the smoking, and very little
of taking snuff. Furthermore, it is not neces-
sary to use large quantities of tobacco, as the
effect depends rather on the idiosyncrasy of the
patient than on the amount used. Other val-
uable signs of chronic nicotinism are early ex-
haustion, pains in the legs, tremor, meteorism,
ettteralgia, palpitation, arrythmia, retrobulbar
neuritis, narrowing of the visual field for green
ami red, ami headache in the occipital region
resembling migraine or vertigo. The X-ray
may show a gastrospasm, just as may be seen
III sclerosis of the arteries of the stomach, in
gastrin or duodenal ulcer, tabes, tetany, chronic
lead poisoning, reflex form disease of other
abdominal organs and neuroses of various
sorts, Gastrospasm from chronic nicotinism as
well as from the other causes mentioned may

HYPOPLASIA OF AETER1ES 111

manifest itself clinically by severe attacks of
pains which may radiate to the back and recur
at intervals of weeks for a period of years.

In passing, I wish to mention a cause for
striking and obstinate epigastralgia which can
hardly be influenced by therapeutic measures
and which may be associated with enteralgia,
flatulence, and meteorism. This condition is
hypoplasia of the arteries, especially of the
splanchnic vessels. This affection may be sus-
pected when we find the usual symptoms of
status thymico-lymphatico-hypoplasticus. These
are hypertrophy of the lymphatic organs, such
as the glands, the follicles on the tongue, and all
the tonsils. There is hyperplasia of the thymus,
O formation of the epiglottis, abnormal nar-
rowness of the vessels, absence of jugular pulsa-
tion of the aorta and an abnormally small heart
in spite of the fact that it may be hypertrophied.
Finally, there are failures of development of the
mature sexual characteristics, or signs of a
heterologous sexual nature, as, for instance, the
female hair type at the pubis or female forma-
tion of the mons veneris, sparse beard, or absence
of hair at the anus or perineum, rounded form
of the arms and thighs, abnormally high voice,
small and soft testicles and small penis. The
masculine features in the female patients are of
the same importance.

Gastralgia may also occur as a result of dis-

112

ABDOMINAL PAIN

ease of the nervous system. In this connection,
I wish to mention the gastralgias seen in ane-
mia, especially chlorosis, and in pulmonary
tuberculosis. The dyspeptic complaints and
gastralgias in chlorosis are explained by most
authors on the basis of a gastric ulcer. Ac-
cording to my experience, however, gastric ulcer
is rare in general chlorosis, and we must explain
the pains in this condition by hyperacidity or
nervous hyperesthesia of the stomach. The
subjective symptoms closely resemble those of
gastric ulcer. They are not uncommonly pro-
duced by psychical emotion, physical exertion, or
menstruation. It is characteristic that the entire
stomach area is tender, and this tender area
may be enlarged by artificial inflation of the
stomach. If we find only a localized tender-
ness, it will be chiefly in the region of the cosliac
plexus. Superficial pressure or very light per-
cussion may cause more intense pain than deep
pressure. The characteristic, segmentary, skin
hyperesthesia of Head is absent. The pains do
not radiate and are not influenced by change of
position. Finally, we may note the effect of
the galvanic treatment of iron, or iron and
arsenic. The sequence of the symptoms is im-
portant in that in chlorosis there are at first
disturbances or anomalies in menstruation, pal-
lor, general fatigue, and palpitation, while the
stomach complaints appear later. In gastric

PULMONABY TUBEHCULOSIS

113

ulcer the sequence is more likely to be the
reverse.

Pulmonary tuberculosis plays even a more
important role in the production of epigastral-
gia than does chlorosis. In not a few cases, the
gastric disturbances are the first symptoms of
pulmonary tuberculosis, and they may be mis-
taken for gastric ulcer. In addition to the usual
symptoms of incipient tuberculosis in cases
where the gastric manifestations predominate,
there are two which are of great importance,
namely, tachycardia, which is the opposite of
the bradycardia one often finds in gastric ulcer,
and tenderness of both vagi in the neck, a sign
of toxic neuritis of this nerve. There is some-
times tenderness of the cervicobrachial plexus
above the clavicle. There may be increased
muscle tonus over one or the other lung apex,
and the trapezius and sternocleidomastoid may
be tender on pressure or percussion. Cough
appears regularly after meals, especially after
supper. Sometimes the cough is produced im-
mediately after intake of food and is a result
of the irritation by the food of the vagus supply-
ing the oesophagus or stomach, and transmission
of this irritation to the branches of the nerve
going to the lungs.

Furthermore, the gastric pains are favorably
influenced by improvement of climatic condi-
tions. The tachycardia may be replaced by a

ABDOMINAL PAIN

bradycardia if we are dealing with a compres-
sion irritation of the vagus nerve. This com-
pression may be due to enlarged mediastinal
glands, scar tissue, or mediastinal pleurisy. In
these cases such a neuritis of the vagus may
even produce hematemesis as a result of a
trophic degeneration of the mucosa as well as
pains, pylorospasm, and retention, as demon-
strated by the X-ray. The sequence of symptoms
will also be of importance, as there will appear
first the gastric and later the pulmonary symp-
toms, and the objective signs from both regions
will be present.

Finally, I wish to mention that it is not rare
to find a combination of gastric ulcer and tuber-
culosis, or perigastritis on a tuberculous basis
or tuberculous ulcer.

There are other causes for affections of the
vagus with epigastric pains, as, for example,
in lead poisoning affecting the gastric branches
of this nerve. I once saw an affection of the
mediastinal portion of this nerve, caused by an
aneurism of the arch of the aorta. In addition,
central affection of the vagus may occur in
brain tumors, and more commonly in disease of
the spinal cord, as in the gastric crises of tabes.
There will be no difficulty in diagnosing the
typical cases, but there are often atypical forms.
These crises may be of short duration, one to
two hours, with or without vomiting, the onset

EPIGASTRIC PAINS

and termination may be gradual, the attacks
may be repeated at intervals of days or weeks,
or it may represent just a single attack. We
must therefore examine the central nervous
system in all cases of epigastric pains, especially
the pupils and reflexes. If there is any doubt,
we should examine the cerebrospinal fluid for
syphilis, albumin content, number and types of
cells, Nonne-Appelt, Pandy, and collodial gold
tests.

The sympathetic nerves may cause epigastric
pains in the same way as is seen in affections of
the vagus. We must mention the genuine neu-
ralgias of the eccliac plexus, and the epigastric
pains in Grave's disease and in angioneurotic
edema. The latter is sometimes associated with
intense gastric pains, nausea, and vomiting, but
the diagnosis is made on the other typical signs
seen in the skin, visible mucous membranes, and
joints.

Other forms of nervous epigastric -pains are
the nervous acid hyperesthesia of the stomach,
in which the complaints are like those of hyper-
acidity in gastric ulcer, and in which the pains
are relieved by alkalies. The chemical examina-
tion will, however, show a normal or subnormal
acidity.

We spoke of the differential diagnosis of the
gastric diseases in the previous paragraphs.
We shall now discuss diseases of other organs

116

ABDOMINAL PAIN

or tissues which may cause pain in the epigastric
region.

The appearance of pains shortly after meals
or after a dietetic error with tenderness are not
distinctive only of gastric disease, as they may
also occur in such diseases as cholelithiasis. Cold
foods or drinks especially may cause pain
in the gallbladder or liver. Complete relief of
pain after vomiting points, as a rule, to gastric
disturbance, while the pain may be only slightly
or not at all relieved in gallstone disease by this
act. In some cases of gallstones in which there
is an accompanying pylorospasm, there will be
relief of the pain after vomiting. Kxcept in
cases of phlegmonous gastritis or acute peri-
gastritis, increase of temperature will always
suggest either cholecystitis or periappendicitis.
Radiation of the pain to the lower abdomen
speaks against gastric disease, except in cases
of gastroptosis of a severe grade. In regard
to appendicitis, I wish to add that the fact that
the patient recovers immediately after the at-
tack and may even be able to go home does
not point against a possible destructive perfor-
ative appendicitis. This is especially so if the
perforation has occurred in a previously walled-
off space.

I wish to mention that hematemesis may occur
in appendicitis, in which case it is caused by
retrograde emboli into the stomach, causing

CHOLELITHIASIS

superficial ulcerations. It may also be a result
of a toxic necrosis of the gastric mucosa. Of
greatest importance in such cases is the location
of the local tenderness and rigidity. Great diffi-
culties will be met when gastric ulcer and ap-
pendicitis exist at the same time.

In regard to cholelithiasis, we must remember
the principle that stomach cramps in the left
epigastrium with tenderness on pressure and
percussion over the same area and with rigidity
of the left upper rectus all point to a gastric
affection while, on the other hand, subjective
symptoms in the right epigastrium may be due
either to gastric ulcer or to cholelithiasis. When
there are subjective symptoms in the left side,
but no objective findings, we must remember
the possibility of a gallbladder affection. This
localization of the pain on the left side has been
variously explained. We must first of all con-
sider an abnormal location of the gallbladder,
stone in one of the bile ducts in the left lobe
of the liver, and stone in the common duct,
although in this latter case the pains are rather
lower down towards the mesogastrium. Ger-
hardt explained it by simultaneous, acute con-
gestion of the left kidney. I think that this
abnormal localization of the pains is caused
rather by the accompanying gastrospasm. Fi-
nally, we must consider the possibility of an
accompanying pancreatitis arising via the lym-

118

ABDOMINAL PAIN

phatics from the gallbladder. As evidence for
gastrospasm in gallbladder disease, we have the
X-ray findings and, at times, such signs of gas-
trospasm as intermittent stasis, palpable tumor,
etc

The findings pointing to cholelithiasis are dys-
peptic symptoms in general which are not re-
lieved by vomiting, together with icterus, itching
of the skin, long duration of the attack of pain,
increase of the pain on deep inspiration, or
even inability to breathe deeply, sudden cessa-
tion of the pains, radiation to the right side of
the back or shoulder, chill, fever, tenderness
over the gallbladder region, skin hyperesthesia
over the liver, both anteriorly and posteriorly,
and reflex rigidity of the right upper rectus
muscle. Meteorism of the stomach may be pres-
ent, the pains may be increased when the patient
is on his left side, less often when on his right
side, achylia is rather common, there may be
enlargement of the liver with tenderness of this
organ on deep pressure or percussion, and there
may also be a perihepatic rub. Occult malena
may be present, although it speaks rather for
an ulcer, due either to ulceration of the walls
■of the gallbladder or ducts in the course of a
symptomless perforation into the bowel or stom-
ach. In this instance there may be manifest or
occult hematemesis. Other possible causes for
bleeding are capillary, passive hyperemia caused

(ESOPHAGEAL- FAN CBEATIC DISEASES

119

by pressure of the enlarged gallbladder on the
duodenum, or a pylephlibitds of the portal vein
with thrombosis. Chronic icterus may of itself
lead to a hemorrhagic diathesis and nmlena.

We must also consider oesophageal and pan-
creatic diseases as possible causes of epigas-
tralgia. Among the oesophageal causes are the
cardiospasm due either to a peptic ulcer, to a
beginning neoplasm or oesophagitis from any
cause whatsoever, or to functional or anatomical
disease of the nervous supply, especially of the
vagus. Carcinoma or ulcer of the lower part
of the oesophagus may cause epigastric pains
even if there is no cardiospasm. The pains may
radiate to the shoulder-blade and are increased
by the intake of food. Dysphagia may be ab-
sent. The cardiospasm produces a cramp-like
pain, located behind the xyphoid, or in the angle
between it and the costal arch. It may occur
only during swallowing or one to two hours
after meals. We may be able to find the ob-
struction to the passage of food. The vomitus
shows no HCL, but may contain lactic acid
and lactic acid bacilli as signs of stasis. CEsopha-
goscopy and X-ray will further clear up the
diagnosis.

We may meet with great difficulties in dis-
tinguishing pancreatic colic from gastric or
hepatic colic. The cause for such colic is ob-
struction or narrowing of the pancreatic duct

120 ABDOMINAL PAIN

either by a gallstone low down in the common
duct, pancreatic stone in the duct of Wirsung,
compression from the outside, as from a tumor
or infiltration, bleeding or necrosis in the pan-
creas, acute or chronic inflammation, scars, ab-
scess, pancreatic cyst, and, occasionally, para-
sites in the ducts.

The pains may be very marked and are some-
times uninfluenced even by morphine. The pain
may be accompanied by symptoms of shock.
We may consider pancreatic disease if the
patient complains of milder colics which are
situated deeply in the abdomen. Of special im-
portance is the finding of severe diarrhea during
the attack of colic. If there is a palpable cyst
or tumor, the diagnosis is easy. The finding of
concretions of calcium carbonate and calcium
phosphate in the stools also speaks for pancre-
atic disease. In cases of complete obstruction
of the pancreatic duct we find signs of pancre-
atic insufficiency, such as a stool of acid reaction,
gray color, salve-like consistency, and abnor-
mally large quantity in each bowel movement.
Fat may nometimes be seen in the stools, and it
rcfcmhlcti fluid oil. Even as much as sixty per
cent, of the entire intake of fat may be found
tinahftorljctl. We also find an abnormally large
quantity of neutral fat drops, and we may pro-
voke a fatty stool by giving a fat meal of 250
grams of butter with 250 grams of grueL

PANCREATIC DISEASES 121

In finding fatty stools, we must remember
that icterus, amyloidosis and tuberculosis of the
intestine or mesenteric glands may also cause
fatty stools even when the pancreas is normal.
The presence of much striped muscle in the
stools after Schmidt's test meal is of diagnostic
importance but is also found in increased per-
istalsis of the bowel or atrophy of its mucosa
after a severe catarrh. Sclimidfs nuclein test
may also be positive. After an oil-test break-
fast there will be no trypsin in the aspirated
stomach contents and in the stools. Absence
of indican in the urine, in spite of a meat diet
and normal intestinal motility, is characteristic.
Ptyalism, glycosuria or alimentary glycosuria,
maltosuria, and alimentary lecithinorrhea may
be found. Adrenalin in the eye causes mydri-
asis, and we occasionally find extreme hunger
and thirst. Urobilinuria and even bilirubinuria
are not to be considered as pointing against
pancreatic colic, as compression or constriction
of the pancreatic duct may occur from causes
in the common duct with accompanying damage
of the liver cells.

If such signs of pancreatic insufficiency or
palpable tumor are not present, we will be able
to make only a tentative diagnosis. Pancreatic
patients are usually stout people, and are often
chronic alcoholics with arteriosclerosis or history
of previous gallstone disease, and sometimes

122

ABDOMINAL PAIN

with a cirrhosis of the liver. Other and less
distinctive signs are polyuria, restlessness of
the patient's motor system, and sometimes hal-
lucinations or delirium. The pains radiate to
the back, above the sacrum, or in a fan-like
manner downwards toward the lower abdomen,
sometimes even to the wings of the ilium.

The radiation may be girdle-like and is due to
an involvement of the coeliac plexus. The pains
may show two different types, either intermit-
tent with intervals of partial relief for one or
two days and with no complete freedom from
pain during these intervals, or continuous, in-
tense, and of such increasing severity that the
patients may have to crouch in order to obtain
relief. Both types are found most frequently
in indurative pancreatitis or in carcinoma of
the body of the pancreas. Sometimes a tumor
from some other place, but infiltrating the pan-
creas, may cause similar effects. Carcinoma,
beginning in the head of the pancreas and sec-
ondarily involving the body, may also cause
such an attack. The intermittent type will very
much resemble the crises of tabes or of aneu-
rism of the abdominal aorta. We may meet
with pains of a mild colicky or pressing nature,
as signs of hyperesthesia of the coeliac plexus,
resulting from anatomical or functional dis-
ease of the pancreas. Such symptoms are also

ANEUBISM OF ABDOMINAL AOETA

found in gastric or pancreatic achylia, hypothy-
roidism, and general neurosis.

We must differentiate between the gastric
crises of tabes and carcinoma of the pancreas.
Tabes generally appears at long intervals, even
weeks or months, and the tabetic attack itself
lasts longer, sometimes as long as a week. The
blood pressure is increased if there are vascular
crises as well, and the usual signs of tabes may
also be seen.

Aneurism of the abdominal aorta may be
confused with carcinoma of the pancreas, be-
cause the pulsation of the aorta in the latter
condition may be very prominent and the over-
lying pancreas may transmit this pulsation from
the aorta and cause a systolic compression mur-
mur over the vessel. The diagnosis will be
based on the fact that the pulsation in aneurism
is expansile, while in tumor the heaving is just
in one direction. Furthermore, there will be no
retardation of the femoral pulse in tumor of
the pancreas when compared with the apex beat
or radial pulse. The course will also be of some
value, especially the cachexia and loss of weight,
while in aneurism the patient may feel well
for years. The pains in abdominal aneurism
occasionally radiate to the lower extremities,
especially when the patient is walking, and are
dependent on the position of the body. Some
aneurism patients learn that the pains disap-

124

ABDOMINAL PAIN

pear on assuming certain positions, while pan-
creatic patients always crouch.

In passing, I wish to mention that aortitis
and sclerosis of the abdominal aorta with nar-
rowing of the beginning of the cceliac artery
may produce similar crises. Such crises have
been observed in chronic malaria and were even
associated with hematemesis.

In discussing ulcerations of the upper gastro-
intestinal tract, I wish to point out that there
are gastric ulcerations in tabes which are a
result of affection of the vagus.

Ulcer of the jejunum and of the duodenum
may closely resemble one another clinically. The
former may be syphilitic in origin or it may be
the result of a gastroenterostomy.

The cramp-like pains of duodenal ulcer are
characterized by their periodicity, occurring
most often during the cold seasons, sometimes
under psychical effects, remain four to six
weeks, and then disappear for a month or even
for a year, to again reappear as before. We
observe that the intervals become shorter as the
disease progresses. The attacks begin, as a
rule, two to five hours after meals, rather earlier
after fluids than after solids, and we sometimes
see that foods which are difficult to digest cause
no pains, while a bland diet tends to aggravate
the symptoms. The pains also appear when
the stomach is empty, especially at night, and

this so

fnod n

DUODENAL ULCER

125

this so-called hunger pain may be relieved by
food or alkalies. This hunger pain is by no
means pathognomonic for duodenal ulcer, as
many authors assume. It also occurs in gastric
ulcer, simple hyperacidity, digestive hyperse-
cretion, achylia, carcinoma, periduodenitis, peri-
cholecystitis, jejunal ulcer, chronic periappen-
dicitis, tuberculosis of the mesenteric glands,
parasitic diseases, such as tamiasis and occasion-
ally, in affections of the colon, as carcinoma.

Anacidity and hyperacidity occur in duodenal
ulcer, but hyperacidity is the rule. Hyperse-
cretion is rare. Eructations and heartburn are
rather common.

Another important symptom is the acute
malena, either in the stool or in the duodenal
contents which are removed with a duodenal
tube. This bleeding may be brought about by
a coarse, irritating diet. It is generally sup-
posed that duodenal ulcer produces occult blood
in the stools but none in the vomitus, and that
blood in the vomitus points to a gastric ulcer.
This is not always true, as the patient may
vomit blood, especially if there is a duodenal
stenosis, while a gastric ulcer patient may have
only malena but no hematemesis.

All the above-mentioned signs are not char-
acteristic for duodenal ulcer, as they may also
occur in gastric ulcer near the pylorus, and we
must, therefore, consider them as signs of ulcus

126 ABDOMINAL PAIN

juxtapyloricum. Of greater value for the diag-
nosis of duodenal ulcer will be the objective
tenderness on palpation or percussion to the
right of the midline, about one and one-half
finger-breadths to the right of a point about
midway between the xyphoid and the navel.
Sometimes this tenderness must be searched for
by a thrusting palpation with the tips of the
fingers. The pains may radiate to the right
chest, the back, to the right of the spine or to
the shoulder-blades. Hyperesthesia of the skin
may be present to the right of the tenth to
twelfth thoracic vertebra. We must also re-
member that duodenal ulcer is common in the
male.

A tympanitic area which is constant and cir-
cumscribed may be found over the dilated por-
tion of the duodenum proximal to an existing
stenosis. The X-ray may sometimes decide in
cases of doubt, and is to be considered as a val-
uable help in all cases. The X-ray findings
are early food expulsion from the stomach, with
a food residue six hours after ingestion of the
test meal in spite of the hypermotility. The
duodenal cap is persistently filled although the
stomach is empty, the cap is distorted, and a
"Nische" may be seen in penetrating ulcer. The
usual signs of stenosis will be seen if the duo-
denum is narrowed.

The differentiation between duodenal ulcer

and cl

PEBIDUODKNITIS

127

and cholelithiasis rests on the following points.
Attacks which always last for several days with-
out periods of appreciable relief point to gall-
stones, as does a large liver which shrinks after
the termination of the attack. Generally speak-
ing, icterus points to cholelithiasis rather than
to duodenal ulcer, but icterus is often absent in
gallbladder disease and may be present in duo-
denal ulcer if it is near the papilla of Fater,
where it causes inflammation or adhesions with
obstruction to the outflow of bile. Urobilinuria
is of greater value. If it is present during or
after such an attack, when there.was no previous
icterus, it points to gallstones. Fever may occur
in acute periduodenitis in duodenal ulcer.

In making the diagnosis of duodenal ulcer,
we must remember that the etiology need not
be that of a peptic ulcer. Such an ulcer may
follow burns, arteriosclerosis, uremia, septic dis-
eases, tuberculosis, and syphilis.

Fibrous periduodenitis may cause pains which
resemble those in duodenal ulcer, even if the
former condition is due to ulcer, pericholecystitis,
congenitally short hepato-duodenal ligament, or
syphilitic scars. The constant absence of malena
and the X-ray findings will be of importance in
distinguishing it from duodenal ulcer. Hyper-
secretion of the duodenum and pancreas point
rather to ulcer than to a periduodenitis. Peri-
duodenitis below the papilla of Voter will show

128

ABDOMINAL PAIN

the characteristic features such as signs of an
interference with the gastric emptying, plus
the constant presence of bile and pancreatic
juice into the stomach contents.

Rare causes of a duodenal stenosis are pri-
mary carcinoma of the duodenum, primary
tumors of some other nature in this region, and
congenital anomalies.

Similar epigastralgias may be brought about
by a stenosis caused by extraduodenal lesions
but without the presence of a periduodenitis.
These are tumors of the pancreas or gallbladder,
neoplastic or tuberculous glands, wandering kid-
ney, and retroperitoneal tumors, etc. Periduo-
denitis as well as jejuna! ulcer may occur after
a gastroenterostomy.

Other complications may result from this
operation, such as adhesions between the stom-
ach and colon, with narrowing of the latter,
gastrocolic fistula, incomplete jejunal stenosis,
and too rapid passing of food from the stomach
into the bowel. All these conditions may pro-
duce epigastralgia. In all diarrhea occurs short-
ly after meals, and the patients complain of
dyspeptic symptoms.

We shall now consider hernia as another cause
for epigastric pains. The first to be mentioned
are epigastric hernias and hernia of the lateral
abdominal wall. These cause cramps which
sometimes occur after meals, and which may be

accompanied by vomiting. These symptoms
also occur after motion or upon shaking up of
the abdominal contents, as in coughing. The
pains may be localized to the hernial region, or
they may radiate, girdle-like, around the thorax
towards the spine or upwards to the shoulders,
rarely towards the bladder or rectum. In prac-
tically all cases we find that certain positions,
especially the supine, considerably relieve the
pains. We may surmise the origin of these
pains when we remember that the hernial con-
tents consist of omentum or subserous Iipomata
which are connected to the peritoneum by a
fibrous cord. As evidence that these are really
the cause of the pains, we find that the hernia
is tender during the attack or during contrac-
tion of the abdominal muscles. We must re-
member that the mere presence of these hernias
should not prevent us from looking for other
causes of the epigastric pain.

Postoperative hernias may also cause such
symptoms. Hernia following trauma to the
abdominal wall may likewise cause pains. Dys-
pepsia and pains may be due to compression
and adhesions in the hernial sac. These symp-
toms can often be greatly relieved by an ab-
dominal support. Femoral or inguinal hernias
or large inguinal rings may also cause crampy
pains in the epigastrium. The cause for these
pains may be suspected when the patient com-

130 ABDOMINAL PAIN

plains that the stomach cramps appear while
he is walking about. A periodic tenderness of
the spermatic cord or a unilateral tenderness of
the rings may also point to the nature of these
hernial disturbances.

There is another type of hernia which causes
cramp-like epigastric pains, which radiate to the
left shoulder. This is a diaphragmatic hernia.
We must assume, in these cases, that there is
a stretching of the abdominal organs which are
displaced into the thorax, this being especially
the case with the stomach. We will therefore
find the pains after large meals or bodily exer-
tion. The patient will show signs of microgas-
tria, that is, the patient can take only small
quantities of food, he feels that the stomach
quickly fills up, and he has a tendency to
meteorism, temporary dyspnea, anxiety, and op-
pression. Objective examination reveals a dis-
location of the heart and lungs, high-grade
tympany with changes in character and extent
and which reaches high up, depending on the
fullness of the stomach. A bubbling sound may
be heard over this tympanitic area in the thorax,
and the X-ray will further show signs of this
condition. Hematemesis may occur either as a
result of disturbances in the circulation of the
stomach or from real gastric ulcer due to a
tearing or kinking of the stomach.

We must also mention Addison's disease, of

MESENTERIC-OMENTAL CYSTS 131

which there are two types. This may produce
epigastric pains which also run along one or
both sides of the hypochondrium, or the picture
may closely resemble the gastric crises of tabes,
but is accompanied by vomiting and diarrhea.

Mesenteric and omental cysts and. tumors
may cause crampy, epigastric pains. More im-
portant is the fact that tuberculosis of the mes-
enteric glands may lead to cobcky or constant
pains in the upper part of the abdomen or ileo-
cecal region. This so-called tabes mesenterica,
which occurs practically only in the young, will
be diagnosed by the pain, tender, palpable,
knoblike tumors, rise in temperature, which may
be of a hectic character, anorexia, pallor, loss
of weight, and the striking distention of the
abdomen with otherwise severe emaciation, often
vomiting during the attacks, and sometimes
fatty diarrhea or light-colored stools which may
be due to obstruction of the mesenteric lymphat-
ics by the enlarged gland.

Such cases of enlarged mesenteric glands may
simulate duodenal ulcer for years. These cases
may show a local reaction after subcutaneous
injection of tuberculin, in the form of cramps in
the stomach region.

Cardiovascular and respiratory disease may
also cause epigastric pains. Angina pectoris
is discussed elsewhere. Paroxysmal pulsation
■of the abdominal aorta may cause such pains,

132 ABDOMINAL PAIN

especially in females. The pains may be so
intense as to be mistaken for gallbladder colic.
It is characteristic that the patients complain
of an epigastric pulsation which may reach to
the navel and which may accompany the pains.
The patients feel as though the heart has fallen
down into the abdomen. We may see the exag-
gerated pulsation of the abdominal aorta dur-
ing these attacks, while this vessel may appear
entirely normal during the intervals.

Epigastric pains may, furthermore, be found in
increased blood pressure, dilatation of the right
side of the heart, especially when it is a result
of emphysema, mitral disease, myocarditis, and,
generally, in all cases of functional disease of
the tricuspid valve. The patient complains of
a constant, moderate pressure in the epigas-
trium, which may be explained by the passive
hyperemia of the liver, especially if there is
increased urobilin in the urine and tenderness
which is most marked in the left lobe of the
liver. This constant pain or sensation of pres-
sure may develop into intense cramp-like pains
which extend behind the sternum. Exacerba-
tions may be due to physical or psychical exer-
tion or emotion. The regular meals will, how-
ever, not influence the pains, while potassium
iodide may afford relief.

The differential diagnosis between primary
myocarditis on an arteriosclerotic basis and

FIBRINOUS PERIHEPATITIS

arteriosclerosis of the stomach arteries or of the
abdominal aorta may be very difficult, as both
conditions cause pain on bodily exertion. In the
sclerosis of the abdominal aorta, there will be no
continuous pain in the intervals, the aorta itself
may be tender, and the pain may be influenced by
food and will not be produced by pressure on
the epigastrium. The fact that the pains do not
reach behind the sternum has even more diag-
nostic value in disease of the abdominal aorta.
The facial color is of importance in that all
cases with increased pressure in the right heart
show a cyanotic color during the attack, and
the patient may become livid in the later course
of the disease.

There are two more conditions under which
the liver may be responsible for epigastric pains
in heart lesions. One is the fibrinous perihepati-
tis due to the passive hyperemia, and the other
is an abrupt liver enlargement caused by an
acute passive hyperemia of the liver, in the
course of an acute dilatation of the heart. In
the perihepatitis, we find the perihepatic rub,
pain on movement of the diaphragm, as in deep
breathing, coughing, or sneezing, tenderness m
the intercostal spaces, and fever and asynchro-
nous breathing on the two sides of the chest.
The latter sign may be a result of a previous
passive hyperemia of the liver. In regard to
the before-mentioned abrupt liver enlargement

134 AMDQMTS

winch is doe to passive hyperemia, we must re-
member that there may be severe, cramp-like
pains extending behind the sternum, with cold
sweats, vomiting; pallor, cardiac anythmia, in-
drawn abdomen, and exquisite tenderness of the
epigastrium; all of which may resemble the pain
of a perforated peptic ulcer or acute pancreati-
tis. All these symptoms may disappear if the
heart condition is improved by cardiac therapy.

Disease of the small bowel and colon as far
down as the sigmoid or affection of their peri-
toneal coverings may cause epigastric pains.
These pains may even have a definite relation
to the intake of food, appearing three to four
hours after eating if the process is located below
the cecum. This corresponds to the time it
takes the food to arrive in this region. We
often see attacks of pain immediately after
eating, even if there are no adhesions to the
stomach.

I cannot too strongly emphasize the point
that pains may occur immediately after eating
in lesions of the intestines, and I wish to repeat
the words of Trousseau, that half of the so-
called stomach pains are really caused in the
colon. Of especial value is the statement of
the patient that passage of gas per rectum re-
lieves the pains, while belching has no effect,
that the pains appear to travel from right to
left and are not constantly located in the epi-

LEAD COLIC — MUCOUS COLITIS

135

gastrium, but may at times be above or below
the navel, and that they may not be severe but
of a pinching character and are often accom-
panied by borborygmi in the colon, which are re-
lieved by local heat or moderate pressure. The
attack sometimes assumes a wave-like character
in intestinal colic and is of short duration. The
pain will cease when the bowel is empty and
reappear when it is filled. The pains may also
be relieved after passage of stool or flatus, and
vomiting is sometimes present at the end of
the attack. In this connection it is well to
remember that gallstone and renal colic may
produce a similar picture. Of course, in deter-
mining the origin of epigastric pains, we will
have to consider such findings as tumor, vomit-
ing, and especially colon bacilli and urobilin in
the vomitus, and rectal and chemical examina-
tion of the stool.

Lead colic and mucous colitis may also pro-
duce epigastric pains. The pain in the latter
condition may be produced by mucus formation
in the bowel and will be characterized by intense
and lasting pains and especially by the presence
of membranes in the feces, particularly if they
are of a tube-like formation and appear at the
end of the attack. The attacks in mucous colitis
may be single or repeated at intervals of weeks
or months. It occurs chiefly in female patients
who show a general neurosis and affection of

136 ABDOMINAL PAIN

the genital tract. Not rarely, we can palpate
the contracted sigmoid, which seems to be the
place of predilection in this condition.

Such a colonic spasm may also occur as an
entity by itself and not as mucous colitis, espec-
ially in the transverse colon. The epigastric
pains are colicky and last several hours. In
one such case in my experience, the pains were
relieved only after diuretin, and I believe that
in this case the condition was due to arterio-
sclerosis of the vessels of the transverse colon.

Renal affections may produce epigastric pains
of a pressing, throbbing, or sticking nature.
They occur in all kinds of affections of the kid-
ney or its fibrous and fatty capsule, and are
usually accompanied by lumbar pains. Cramp-
like pain occurs only in renal or ureteral colic.
The latter may also cause epigastric pains at
the onset. But even under these circumstances
the diagnosis will not be difficult, as the pa-
tient will, as a rule, say that he feels vague or
moderate pains in the flanks with radiation
along the ureters to the bladder or genitalia.
We will have to look for tenderness over the
kidney on deep percussion or pressure, hyper-
algesia over this area, and tenderness along the
ureter and testicle on the diseased side. Traces
of albumin, some red blood cells, and the X-ray
will support the diagnosis. The pains may ulti-
mately spread over the entire abdomen, and

WANDKKINU KIDNEY

there may be severe pains in the bladder with
vomiting and copious stool during the attack.
The attack may last for a few hours and may
be accompanied by chills and fever. The symp-
toms described in this paragraph may, however,
also occur in disease of the intestines, especially
in stenosis. I saw a case of old fibrous peri-
tonitis of the pelvis which was caused by appen-
dicitis and which was followed by rectal stenosis
with a picture as just described.

Among other conditions of the urogenital
tract which may produce epigastric pain is a
wandering kidney. I wish to emphasize the
fact that we are too ready to make the diag-
nosis of wandering kidney as being the cause
of epigastric pain, especially if we can find a
somewhat low or movable kidney. It is only
when the pains disappear on replacing the kid-
ney in its normal location, and where a fitting
bandage will bring lasting relief, or when the
pains disappear when in the horizontal position
that we are justified in assuming that the wan-
dering kidney is the cause of the trouble.

On the other hand, shaking up of the body, as
in jumping or jolting in a carriage, will again
produce the symptoms. Unless we have these
characteristics we must first rule out all other
causes, including the neuroses, before we can
consider the wandering kidney as the real cause
of the pain. A wandering kidney may produce

138

ABDOMINAL PAIN

very severe, cramp-like pains in the epigastrium
with nausea, vomiting and constipation. These
symptoms may be due to stretching of the
nerves or vessels, torsion of the ureters, or inter-
mittent hydronephrosis. We must not forget
that the wandering kidney may be diseased with
tuberculosis, stone, etc. The wandering kidney
may occasionally produce epigastric pains in an
indirect manner by pressing on the pylorus or
duodenum with resulting signs of stenosis of
the gastrointestinal tract. AVandering kidney
may also produce a pure reflex epigastralgia,
especially in nervous people.

Another condition in which epigastric pains
of this nature may occur is diabetes. The cause
may be in the disease of the pancreas. The
pains may appear as in tabetic crises lasting
for hours or days, are very intense, and are
often accompanied by persistent vomiting, nau-
sea, vertigo, occasionally diarrhea, a marked
loss of strength, and symptoms of collapse.
These attacks may be due to inflammation of
the pancreas or solar plexus, or to pressure or
stretching of the latter by a sclerosing affection
of the pancreas. It is of practical importance
that such epigastralgia sometimes resembles per-
itonitis, especially when associated with intense
headache, increased pulse rate, hypotension, and,
occasionally, fever. These may be a warning
signal of impending diabetic coma.

GLYCOSURIA— COLELITHIASIS

139

If glycosuria is present with epigastric at-
tacks of pain we must not forget the possible
relation of such a glycosuria with cholelithiasis,
due either to a mechanical obstruction of the
pancreatic juice or to functional or temporary
anatomical changes in the pancreas, such as
lymphangitis or slight inflammation. It will
be important to note that the glycosuria in these
cases appears only during an attack.

We must also think of the possibility of
cholelithiasis, a condition not at all rare in
women, when there are epigastric pains with
diabetes. We must also remember that the
combination of cholelithiasis and diabetes may
occur in stone or tuberculosis of the kidney,
pyelitis, and gout.

The epigastric pains in gout are accompanied
by vomiting of bile or mucus, and occasionally
by fainting. This is the so-called gastralgic
gout The pain is relieved by pressure, just
as it is in nervous gastralgia. This form of
visceral gout, although described, seems to be
very rare. Gastralgia, combined with dyspep-
tic complaints, may occur as premonitory symp-
toms before an attack of gout in the joints and
may disappear when the attack in the joints
comes on. In cases where the occupation or
clinical symptoms of the patient may lead one
to suspect chronic lead poisoning, we must also

140

ABDOMINAL PAIN

remember that lead gout with tophi and other
symptoms will have to be considered.

Epigastralgia with headaches and vomiting
may be premonitory symptoms of an attack of
eclampsia. Epigastralgia. may also be an aura
before an attack of epilepsy or may be a mani-
festation of petit mal itself.

This type of pain may also occur in Graves'
disease as a sort of visceral crisis. There are
colicky pains along the colon with tenderness
along the large bowel and cceliac plexus, consti-
pation, and anorexia. The symptoms in these
cases may be due to a certain extent to the en-
teroptosis which is such a common finding in
these patients.

We must consider the acute infectious dis-
eases as causes of epigastralgia. This type of
pain may occur in malaria, and it may even be
the only manifestation of the malarial attack.
Mild abdominal pains may be observed a few
days before an attack of ffistivo-autumnal ma-
laria, or it may occur during the attack and
may be accompanied by tormenting singultus.

Gastrointestinal influenza may also cause epi-
gastralgia. This may also be an early symptom
in smallpox and is to be kept in mind when there
are accompanying sacral pains, fever, headache,
and various aches in the limbs. Epigastric
pains are occasionally Initial symptoms in rheu-
matism, typhus, and acute trichinosis, in which

latter

EPIDEMIC MILIAH1A 141

latter condition it is associated with muscle
pains and diarrhea.

Epigastric pains are frequently an early
symptom in epidemic miliaria, in which condi-
tion they are constricting in nature and are also
present about the region of the heart with a
sensation of marked anxiety, dyspnea, and pro-
fuse sweating. Marked epigastric oppression
sometimes occurs in Malta fever, anthrax of the
stomach, and periarteritis nodosa. The latter
condition is associated with profuse sweats and
pains which are independent of the food intake.
Mumps and Weil's disease may also cause this
pain. The pains in the latter condition occur
rather late in the course and are due to involve-
ment of the pancreas. When such epigastric
pains occur in sepsis with bloody vomiting and
diarrhea, as well as meteorism, we will have to
think of embolic erosions in the stomach. In
typhoid we must suspect cholecystitis, diffuse
pancreatitis, suppuration of a spleen or mesen-
teric gland, and perforation of a typhoid gastric
ulcer. Furthermore, the pains may be due to
phlegmonous or diphtheritic inflammation of the
gastric mucosa, hemorrhagic smallpox, erysip-
elas, yellow fever, and pneumococcic sepsis.

Acute, Continuous Epigaetralgia

Our first thought in the presence of a single
and very severe attack of pain in the epigas-

142

ABDOMINAL PAIN

trium of a continuous course and associated with
collapse should be a perforation of a gastric
ulcer. Such perforation occurs most commonly
in peptic ulcer and less often in carcinoma. We
must also remember the possibility of a phleg-
monous, suppurative gastritis of toxic or infec-
tious origin. The diagnosis of the perforation
is made on the following symptoms.

Of importance are the previous history of gas-
tric complaints, rigidity of the abdominal mus-
cles, especially in the epigastric area, shifting area
of tympany over the liver region, cushion-like
bulging of the epigastrium, sometimes a peri-
toneal nib in the liver region, coarse bubbling
rales at the left diaphragm during inspiration,
which are due to the presence of air and fluid
in the stomach, and absence of vomiting, al-
though there are signs of peritonitis and col-
lapse. The collapse and pain may disappear
after a few hours or days, and this may be due
either to a walling off of the process or to a
covering or plugging of the perforation by
omentum or some abdominal organ. In regard
to the localization of the pain, it is not so im-
portant to determine the area as it is to deter-
mine the radiation to the left shoulder, or pos-
teriorly to the left of the spine as the pain may
be located in the same place when due to per-
foration of the gallbladder, spleen, duodenum,
appendix, and peptic ulcer of the cesophagus.

PEKFOBAT10X INTO THE STOMACH 143

Perforation into the stomach from without
may cause similar pains, although the condition
may remain symptomless. Such a perforation
into the stomach may occur in perforative peri-
toneal abscess, carcinoma of the transverse colon
or left lobe of the liver, perforation of a tuber-
culous gland, and rupture of an aneurism, as
of the splenic artery. We must remember that
such a perforation into the stomach may occur
without any appreciable symptoms at all. The
diagnosis of a perforation into the stomach will
be made on the resulting symptoms, such as,
sudden fecal vomiting, direct passage of stom-
ach contents into the colon or vice versa, as is
seen in cases of stomach colon fistula, sudden
biliary vomiting, gross or occult hematemesis,
and copious malena in cases of rupture of an
aneurism. The X-ray findings are also of value.

The preceding compression of the pylorus
may be followed by enlargement of the stom-
ach before the perforation into the organ actu-
ally occurs. What has been said about rupture
of the stomach applies equally to rupture of
the duodenum. Other conditions which may pro-
duce similar symptoms are acute dilatation of
the stomach and acute purulent perigastritis of
any cause. The epigastritis produces very se-
vere pains, which are sometimes accompanied
by collapse, and which extend over the entire
upper abdomen. The pain will be increased by

144

ABDOMINAL PAIN

motion, especially on stooping, the sensorium
may be clouded, and fever may be present. The
fever, polynuclear leucocytosis or leucopenia,
local tenderness or tumor mass, and disappear-
ance of the tumor mass after vomiting will help
in the diagnosis.

I want to mention two conditions which are
rare: volvulus of the stomach, a condition which
can hardly be recognized, and the acute phleg-
monous gastritis or duodenitis. The phleg-
monous gastritis may be due to a gastric ulcer
or carcinoma, trauma and bacterial infection
entering either via the blood stream or mouth.
The symptoms of phlegmonous gastritis are
the severe general symptoms of sepsis, some-
times intense chills, very sudden pain indepen-
dent of bodily motion, and a tender tumor mass
in the epigastrium which may decrease in size
or disappear after bloody, stinking, or purulent
vomiting. This vomiting is of great importance
even in the absence of the palpable tumor. As
this symptom also occurs after a perforation
of an extragastric condition into the stomach
or in carcinoma of the stomach and apparently
after simple but severe catarrhal affections of
the mucosa, the diagnosis will be made with
great difficulty. The effects of poisoning by
the various corrosives will also produce such
gastrites, but they are different in their anatom-
ical nature. Finally, I wish just to mention

CAEDIAC CONDITIONS 145

that acute thrombosis of a stomach vein may
precipitate such an attack.

Among the extragastric conditions causing
acute, continuous, epigastric pain are perfora-
tion of the oesophagus near its cardiac end as
a result of either ulcer or carcinoma. Dyspha-
gia may often be absent in these cases, while
rigidity of the upper abdominal muscles is
present. In cases of rupture into the pleural
cavity, we observe epigastric pains, attacks of
dyspnea, vomiting, and asthmatic attacks.

I wish especially to emphasize some cardiac
conditions which may produce such severe pains,
which are rather pressing in character than
colicky. We must, first of all, mention the true
angina pectoris. If the pain begins in the
epigastrium and later localizes itself in the
characteristic place behind the sternum with
radiation into the left arm, there will be no
difficulty in recognizing the condition as angina
pectoris. There are, not rarely, cases in which
the pain is limited to the epigastrium with radi-
ation towards the navel or back. The attack
may last several hours or may develop into a
status anginosus lasting as long as a week. We
are likely to mistake this angina for a gastric
disturbance, because the attack sometimes fol-
lows a dietetic error and ends with eructations.
Pyrosis, oesophageal pains, nausea, vomiting,
desire for bowel movement or urination, and

146

ABDOMINAL PAIN

slight faintness may also at times occur in angina
pectoris.

Of importance in the diagnosis are strik-
ing pallor during the attack, cachectic anemia,
the marked anxiety, effect of amyl nitrite or
nitroglycerine, history of previous attacks or
evidence of previous heart weakness, and objec-
tive evidence pointing to changes in the aorta,
coronary arteries, myocardium, or signs of ar-
teriosclerosis in the peripheral arteries. The
epigastrium will show no tenderness, and the
abdominal respiration will be unimpaired which
is in contrast to the impairment of the abdomi-
nal respirations in peritonitis, a condition which
may resemble angina pectoris because of the
Hippocratic facies. In passing, I may point
out that the characteristic sensation of anxiety
of angina may be simulated by a similar sensa-
tion which occurs in gallstone attacks.

Acute affections of the heart must also be
mentioned, such as acute pericarditis and acute
infectious myocarditis. Rupture of the heart
into the pericardium, more rarely rupture of
the septum of the heart as a result of anemic
necrosis, rupture of the aorta or coronary artery
or dissecting aneurism of the thoracic aorta;
all these may cause epigastric pain. The deci-
sive point in these conditions is the absence of
abdominal rigidity, tenderness, and hyperesthesia
of the skin, except in cases where there is acute

MEDIASTINITIS

passive congestion of the liver. Such pain may
also occur in paroxysmal tachycardia, which
sometimes leads to acute congestion of the liver.
Complete or partial heart block may also cause
epigastric symptoms, which latter may be in
the foreground. In all of these cases we will
find the accompanying and usual circulatory
symptoms. The same is true of aortic insuffi-
ciency, aneurism, and cardioptosis. The cause
for the pain in the aortic insufficiency may be
the irritation of the abdominal aortic nervous
plexus by the exaggerated expansion of the
wall and stretching of the surrounding plexus
or by inflammation of the wall. The aorta,
especially in the region of the cceliac plexus,
will show marked tenderness and pain, which
will be relieved on lying down or upon use of
the icebag. In cases of aneurism, we will also
have to consider primary diffuse affection of
the aorta or coronary arteries and disease of the
vagus-sympathetic system. The epigastric pains
due to cardioptosis appear when the patient at-
tempts heavy lifting.

Among other thoracic conditions capable of
producing epigastric pains are acute purulent
or simple mediastinitis, even when of supra-
diaphragmatic origin. We will think of this
possibility in the presence of fever, dysphagia,
symptoms of mediastinal compression, and sub-
sternal dullness. The X-ray and the presence

148 ABDOMINAL PAIN

of a possible cause for this acute mediastinitis,
such as affection of the lungs, pleura, oesoph-
agus, lymphatics, etc., will aid in the diagnosis.

The pulmonary conditions which may cause
epigastric pain are emphysema, pneumothorax
of the left side, and diaphragmatic pleurisy.
These pains may also be accompanied by vomit-
ing. The diagnosis of pneumothorax will pre-
sent no unusual difficulties, but mistakes are
often made in diaphragmatic pleurisy, where we
must carefully look for increased respirations,
one-sided lagging during breathing, and tender-
ness of the phrenic nerve in the neck, along or
near the sternal borders, or at a point at which
the prolonged parasternal line intersects the
prolongation of a horizontal line drawn from
the tenth rib. Pressure along the lateral borders
of the spine also causes tenderness, as does
pressure in the tenth and eleventh intercostal
spaces.

During the recent influenza epidemic we saw
an acute diaphragmitis, either as an entity by
itself or occurring in the course of a basal pneu-
monia. This may also cause the typical dia-
phragmatic symptoms and findings as mentioned
before.

A fibrinous pleurisy on the left side may lead
to a complication, the acute diaphragmatic pa-
resis, which produces the same symptoms. In

EPIGASTRIC PAINS OF SHORT DURATION 149

these cases, however, the pains will be more lo-
calized to the left side of the chest or hypochon-
drium, and there are a catch in the breath,
dyspnea, cyanosis, high position of the dia-
phragm, which may also be seen with the X-ray,
and dislocation of the heart upwards and to the
right.

Acute, Epigastric Pains of Short Duration
which Are Not Cramp-like in Nature

In this chapter I wish to discuss the sticking,
boring, pressing, or burning pains in the epi-
gastrium. Here we must first mention prac-
tically all the conditions discussed in the chap-
ter on colicky or cramp-like pains.

A rather common cause may be a simple
flatulence without any anatomical lesion of the
intestine. In addition, we must consider com-
pression of the stomach, as in megasigma con-
genita, which may compress the stomach and
cecum. For the same reason, similar pains may
be produced by tumors of the splenic flexure of
the colon.

Of very great importance are acute and
chronic appendicitis and periappendicitis. The
pains need not be crampy or colicky; they may
be only pressing in character and be relieved by
intake of food. They may be so slight in degree
that the patient may attach only minor impor-
tance to them. In this connection it is well to

150

ABDOMISAL PAIN

remember that an epigastralgia with fever is
nearly always of extragastric origin and is usu-
ally due to an appendicitis or inflammatory con-
dition of the bile ducts or porta hepatis. The
diagnosis of involvement of the porta hepatis
will be made on the recognition of a possible
cause, either present or past, such as periappen-
dicitis, or any inflammatory or purulent condi-
tion near the root of the portal vein. There
will also be signs of general sepsis, icterus, even
if only of minor degree, enlargement of the liver,
tenderness over the gallbladder region, acute
tumor of the spleen, ascites, and leucocytosis, as
well as bacteriological findings in the blood. We
must remember that syphilitic disease of the por-
tal vein may cause similar symptoms in this
region.

Among the conditions arising in the liver
itself are acute passive hyperemia and acute
perihepatitis, especially of the left lobe or ad-
jacent part of the right lobe of the liver. There
may be a rub in acute hepatitis which has the
same tempo as that of a pericarditis. The
acute hepatitis in Weil's disease and abscess
of the left lobe of the liver must also be men-
tioned. I saw a case of the latter after retro-
gression of an acute periappendicitis. Hepatic
syphilis may show very severe pains with an
enlarged and tender left lobe of the liver and
positive Wossermann reaction, all of which may

PANCREATIC AFFECTIONS 151

disappear after specific treatment. Neoplasm
or echinococcus of the left lobe may produce
similar symptoms. In regard to diagnosis of
enlargement of the left lobe of the liver, I think
that deep percussion in the back, to the left of
the vertebral column, is of undoubted value.
If the perpendicular height of the left lobe with
this method of percussion is more than five
cm., we can suspect its enlargement, provid-
ing we can exclude extension of the right lobe
to the left.

Pancreatic affections may also produce this
type of pain. The reader is referred to th*
chapter where disease of this organ is dis-
cussed.

Angina pectoris, especially during the stage
of status anginosus, may cause this type of pain.
The same is true of cardiac hypertrophy due to
hypertension, but the pains are transient in this
case and may appear after large meals or after
walking in the face of a cold wind.

Furthermore, I wish to mention the initial
stage of acute tuberculous peritonitis as a pos-
sible cause of epigastralgia of this type, espe-
cially if localized in the left upper part of the
abdomen and resulting either from a tuberculous
pleurisy on the left side, or from tuberculosis of
the mediastinal glands.

Acute circumscribed peritonitis of the parietal
peritoneum may cause this pain when following

152

ABDOMINAL PAIN

a gastric ulcer, carcinoma, or gastritis phleg-
monosa. This circumscribed peritonitis may
later infiltrate or perforate the wall. The diag-
nosis will be made by finding the possible causa-
tive factor in the stomach, circumscribed ten-
derness on palpation or percussion, fever, and
palpable epigastric tumor; later, the local red-
ness, tenderness, edema and swelling of the skin,
absence of epigastric movement on respiration
and a retraction caused by contraction of the
resulting connective tissues after healing of the
process.

Sometimes the infiltration may not come di-
rectly from the causative focus but may result
from a further progression of the peritoneal
abscess. The course may be either quiet or
stormy in these cases. It is self-evident that
other abscesses, such as subphrenic abscess or
perforation through the diaphragm from a pyo-
pneumothorax, may produce similar mild or
severe pain. The pain will be most severe at
the time of perforation through the wall in the
above-mentioned cases.

Similar pains may also arise from disease
of the lower end of the oesophagus. The pul-
monary diseases may come into consideration
when there are complications in the liver, low
position of the diaphragm, or its overloading
by an exudate without the latter's causing symp-
toms, as well as the presence of a pneumothorax

CESOPHAGUS 153

which develops without symptoms. The pain-
less pneumothorax is found especially in pre-
existing severe pulmonary disease with a shrink-
age of the respiratory surface, or in cases where
there is a pre-existing empyema with invasion
of the lung tissue by pus. Such patients often
have no complaints except a continuous, girdle-
like pressing sensation in the stomach region,
gastric fullness after meals, eructations, and
vomiting. Sometimes the complaints very much
resemble those in gastric ulcer, in that the pain
appears after meals, radiates to the back, and
is relieved by alkalies or food. In such cases,
we must also consider the presence of possible
adhesions between the diaphragm and stomach.
Similar symptoms may be present in artificial
pneumothorax, pleurisy on the right side, or
hydropneumothorax. In a case of epigastric
pain which showed similar features, the exam-
ination revealed a seropneumothorax on the
right side, in wluch an existing fibrous medias-
tinitis prevented a dislocation of the heart and
consequently increased the downward disloca-
tion of the liver with resulting pressure on the
stomach.

In regard to nervous affections we must first
discuss the neuralgias of the coeliac plexus which
may occur as a part of an hysterical picture.
Such a neuralgia is characterized by a radiation
of the pain along both sides of the abdomen in

154

ABDOMINAL PAIN

its lower part, reaching to the sacral or gluteal
regions. There is seldom radiation upwards
or toward the genitalia. The patient may have
polyuria, and the stools may be in the form
of small, round pieces like those from sheep.
The exquisite tenderness of the coeliac region
will certainly be of importance, but we may
use this symptom only in a diagnostic sense
when we can exclude an organic lesion such as
gastric ulcer.

Furthermore, we must not forget that retro-
peritoneal diseases, such as cysts or tumors of
the pancreas, aneurism of the abdominal aorta,
and aortic insufficiency, may all produce or be
associated with such a neuralgia of the coeliac
plexus. The tenderness in this region may,
furthermore, be due to an uncovering of the
plexus in cases of diastasis recti, abnormally
relaxed abdominal walls, gastroptosis, enterop-
tosis, and an abnormally forward dislocated
plexus, as occurs in lordosis or retroperitoneal
disease. The examining hand is more likely to
produce pain in these cases than in the normal
people where the plexus is covered by the usual
layers of organs and tissues. Polyuria, although
a useful finding in neurosis, occurs also in neph-
rolithiasis, disease of the pancreas, and gallstone
colic.

Among the other abdominal neuroses which
must be mentioned are abdominal migraine and

CHRONIC EPIGASTRALGIA

visceral crisis of Basedow's disease. Enterop-
tosis is usually present in the latter condition.
There are also cases of reflex hypersensibility
in female patients at the time of menstruation
or in disease of the female genitalia and some-
times as a result of an abnormally full bladder.
Stretching of the peritoneal covering may be
the cause of pain in the latter cases.

Chronic Continuous Epigastralgia

If a patient complains of a constant sensation
or pressure in the epigastrium, as if a stone were
lying in the stomach, or of pains which are in-
creased upon motion or in the upright position,
the reason may be a simple passive hyperemia
of the liver. Only occasionally will this liver
condition produce an intense pain which quickly
reaches its height. It is very important to know
that the pains in passive hyperemia of the liver
are very often the first symptom of the primary
causative disease which is muscular insufficiency
of the right heart, a result of acute or chronic
disease of the myocardium, adhesive or exuda-
tive pericarditis with interference in filling of
the auricles, direct affection of the inferior vena
cava, or disease of the hepatic veins. The diag-
nosis of a passive hyperemia of the liver will be
based on enlargement of the organ, increased
consistency, tenderness on palpation, and per-
cussion in this region and in the linea alba where

156

ABDOMINAL PAIN

the liver is most exposed. This tenderness will
closely correspond to the area of the liver as
outlined by palpation and percussion, but will
be most marked at the linea alba. Urobilinuria
or urobilinogenuria will be very marked. The
symptoms will often improve after cardiac treat-
ment. The liver tenderness which is due to
stretching of the liver will be more marked if
the congestion develops rapidly. Slowly devel-
oping cases, therefore, show mild or practically
no symptoms. On the other hand, if we find
evidence of a passive congestion in the vena
cava but without pains or enlargement of the
liver, we may be justified in assuming that
there must have been a previous condition of the
liver which prevented its enlargement. This
may occur in a previously existing cirrhosis or
fibrous perihepatitis.

In contrast to the passive hyperemia is the
active hyperemia of the liver, which is much
more rare and causes pains in the epigastrium
which are usually as marked in the right hypo-
chondrium as elsewhere. This condition is found
in diabetes, malaria, and sometimes in pernicious
anemia, paroxysmal hemoglobinuria, and hemo-
lytic icterus.

It is also evident that any acute or chronic
inflammation of the liver may cause epigastric
pain, especially when the proeess is most marked
in the left lobe of the organ as occurs in

LIVER, HVUItOPS, GALLBI-AUUEU

157

cirrliosis or lues of the liver, intrahepatic colon-
gitis, acute or chronic abscess of the liver, sup-
purating gumma, ecchinococcus, and neoplasm of
the liver.

Any condition producing a marked stasis of
bile in the liver may cause tenderness by stretch-
ing of the capsule. Pain and tenderness are
rare in this condition, but tenderness on pal-
pation is common.

We must also consider hydrops and chronic
empyema of the gallbladder and chronic cho-
lecystitis with or without stone. In addition to
the continuous pain found in these conditions,
we also find transient pains, especially at mid-
night and after meals. The objective examina-
tion may show the characteristic findings on pal-
pation, enlargement of the liver, occasionally
Siedel's lobe, and tenderness over the incisura
of the liver, especially when the patient is on
his back or left side while the examining finger
is hooked under the right costal arch at the
height of inspiration. Chronic cholelithiasis may
produce symptoms which are similar to hydrops
or empyema of the gallbladder, and it will be
difficult to differentiate these conditions, as they
often co-exist. In cholelithiasis we find, in
addition to the mild and constant pains, an
occasional slight increase of the pain which may
last only a few minutes, and which follows a
meal, psychical emotion, or riding over a rough

158

ABDOMINAL PAIN

road. In addition, we find dyspeptic com-
plaints, especially a sensation of fullness after
food, so that the patients loosen their clothing
after meals, a condition which occurs in peri-
cholecystitis with adhesions as well as in gall-
stones.

A constant, moderate epigastric pain must
also attract our attention to the pancreas. Al-
though the fully developed picture of pancreatic
disease is characterized by the stormy onset
already described, cysts, tumors and chronic
pancreatitis may cause only a mild, constant
pain in the early stages. The luetic type of
pancreatitis is especially likely to produce such
a mild degree of pain with occasional icterus
of marked degree, often glycosuria, anexoria,
and loss of weight.

Conditions which diminish the spaces in the
vicinity of the stomach, such as tumors of the
spleen, left kidney, or adrenal; cysts of the left
adrenal, tumors of the glands, etc., may also
cause the pain under discussion. If these tumors
grow rapidly, they may also cause colicky epi-
gastric pains. This may occur in acute leucemia
or in a sudden increase in size of a cyst of the
adrenals with pressure on the cceliac plexus.
We must not forget that similar pains, or even
those resembling the pains in duodenal or pyloric
stenosis, may be produced by direct compression
of these parts from without.

ABDOMINAL WALLS— TABES

159

Among the supradiaphragmatic conditions
which may produce these pains in the epigastrium
are chronic pleurisy and chronic pneumothorax.

We must also remember that epigastric pains
may be due to disease of the abdominal walls
themselves. Not rarely, a traumatic affection
or strain of a wall which is weak, as in chlorosis,
or normal muscles which are overworked as in
prolonged intense cough may be responsible
for such pains, especially in the recti at their
insertion. We find that the tenderness is lim-
ited to this insertion, and the pains are increased
by voluntary, active tension of the abdominal
musculature. Epigastric pains may also be
observed in rapid loss or gain in weight. The
rapid gain in fat may stretch or tear the root
of the mesentery and thus cause pain.

A tabetic patient may complain of epigastric
pains which are described as girdle-like only
after close questioning. The same is true of
any condition causing irritation of the posterior
spinal roots, such as anatomical lesions of the
vertebra and spinal canal. This is especially
true in tumor or chronic meningitis. In the two
latter conditions there is tenderness on percus-
sion of the spinous processes of the vertebra
as well as hyperesthesia and hyperalgesia of the
skin over the segment from the seventh to the
ninth thoracic segment. Paresthesia may also
be present over this region. I wish to mention

ABDOMINAL PAIN

that a constant or temporary sensation of op-
pression in the epigastrium or oppression dis-
tributed like a girdle, may occasionally occur in
Parlanson's disease.

Lax abdominal walls with or without enterop-
tosis may lead to similar pains, and these may
be increased after meals, without any direct
relation between the quality of the food and
severity of the pain. Epigastric pain may
also occur in individuals with weak muscles and
ligaments as well as in people who have been
in the upright position for some time with
resulting fatigue. The intervertebral spaces
shrink after relaxation of the patient, and this
decrease in the spaces may irritate the spinal
roots.

The diaphragm may cause pains by contrac-
tions of either tonic or clonic nature. These
pains will be bilateral and will correspond to
the insertion of this muscle into the chest wall.
The clonic cramps are seen in prolonged hic-
cough. They also occur in hysteria and last for
several weeks, or the attacks may be of only
short duration. These hysterical cases produce
a loud inspiration with stopping of the chest
expansion, followed by a passive relaxation.
The tonic cramp of the diaphragm is less com-
mon. Intense asthmatic attacks of long dura-
tion may cause epigastric pains by such a tonic
contraction of the diaphragm. It is also found

LOCAL, GENERAL NEUROSIS 161

in tetany and tetanus, and it is especially in the
latter that these girdle pains present the warn-
ing symptom of this fatal disease. In tetany,
we must also consider that quite similar pains
may be the result of a gastro- or pylorospasm
produced by a vagatonia.

Epigastric pain is sometimes experienced
when the stomach is empty. The pains, there-
fore, appear in the morning or late at night
and disappear after intake of food. This con-
dition may be a frequent symptom of a local or
general neurosis, but may be considered in the
physiological domain if not too severe. It ap-
pears physiologically if the general nervous sys-
tem is very sensitive. On the other hand, this
painful empty stomach may be symptomatic as
in gastric ulcer where it is due either to con-
tinuous secretion of gastric juice, intermittent
hypersecretion, or perigastric adhesions which
are stretched when the stomach is contracted.

Old callous ulcers may harbor residues of food,
and this may later produce irritation of the
ulcer. There may be gastromyxorrhea in addi-
tion to the gastric ulcer. Here we find pains,
sometimes very intense when the stomach is
empty, and vomiting of 200 to 300 cc. of pure
mucus, after which the patient feels entirely
well. We observe pain when the stomach is
empty in atrophic catarrh during an early stage
of carcinoma of the stomach. Furthermore,

162

ABDOMINAL PAIN

we must think of a reflex origin, as from para-
sites in the intestine and chronic nicotinism, es-
pecially if the patients smoke cm an empty
stomach. We also find these pains in chronic ap-
pendicitis and periappendicitis, even in the ab-
sence of continuous secretion of the stomach. Mi-
graine attacks are often accompanied by gnaw-
ing pains of the empty stomach. Tuberculosis
of the lungs may produce secondary dyspeptic
complaints with pains during the time that the
stomach is empty, but, as a rule, there is also
pain after intake of food which is less marked
than in gastric ulcer or hypersecretion.

Pain in the Right Hypochondrium

Colicky Pains in the Region of the Gallblad-
der and Right Hypochondrium

There are three conditions which at first at-
tract our attention in the presence of colicky,
periodical pain in the gallbladder region. These
are hepatic colic, duodenal ulcer, and ulcer near
the pylorus.

Liver colic will be characterized by the local-
ization over the gallbladder; the pain comes out
at the right costal arch, and the patient feels
as though he could draw out the pain from this
region. Chills are frequent in the beginning of
the attack, and we not rarely see a later rise
in temperature which may be of various dura-
tions. The pain may radiate to the right chest
or behind the sternum, through the upper part
of the abdomen at the level of the fiver, towards
the back, upwards to the right shoulder, or be-
tween the shoulder-blades, and rarely towards
the thighs. The pains appear, as a rule, at the
height of digestion, about three to five hours
after the meal; therefore most commonly at
about four or six in the afternoon or during the

164

ABDOMINAL PAIN

night, with a preference for the time near mid-
night. The pains may appear shortly after
meals in cases where there are adhesions with
the stomach. Psychical emotion sometimes
brings on an attack. The patient often com-
plains of a sensation of marked fullness in the
stomach during the attack, and he may say that
he feels as though his stomach is coming out.
He may often have gagging or biliary vomiting
during an attack, but these have no effect on
the pain. The patient avoids all appreciable
motion of the diaphragm, as the pains are in-
creased during deep inspiration, and may even
stop the act. The pain is increased in most
cases when the patient lies on his left side and
may feel like a tearing in the liver. The pa-
tient cannot bear the weight of his clothes or a
light touch of the fingers.

Objectively, we find tenderness in the region
of the incisura, at least on deep inspiration, pres-
sure against the liver during inspiration, and
on bimanual palpation of the liver with one
hand on the incisura and the other pressing
against it from the lumbar region. There is
hyperesthesia of the skin over the gallbladder
region and posteriorly between the lower border
of the right lung and posterior costal arch. The
lowest part of the thorax and right hypochon-
drium will be tender on rapid, sharp percussion
of these regions with the ulnar part of the

hand,
also

LIVEE COLIC

hand. Rigidity of the upper right rectus is
also present. The skin reflex of the upper
right abdomen is often absent. There may be
acute swelling of the liver, perihepatic rub, and
lagging of the right hypochondrium during in-
spiration. The gallbladder may be palpable
as a more or less tensely distended, pear-shaped
tumor in cholecystitis, as well as in empyema.
Stones in the gallbladder may sometimes be pal-
pated. Icterus is not common even when the
process is of long duration, or after repeated
attacks. Itching, either localized or general,
may be present with or without icterus. On the
contrary, urobilinogenuria and urobilinuria are
of diagnostic value. The febrile attack may be
accompanied by splenic enlargement or even
herpes. Not uncommonly, the patient com-
plains of increased pains which last several hours
after palpation of the gallbladder, just as it
occurs in the cecal region in appendicitis. Brady-
cardia is a symptom of importance.

The onset of the attack may be sudden or
rather gradual, with a rapid increase in severity
to its acme. The course and severity may last
without any appreciable fluctuation for a few
minutes, hours, or days, to end abruptly in
some cases and rather gradually in others. Such
attacks recur at irregular intervals of a few
days or weeks and reappear after a period of
quiescence lasting weeks, months, or years. This

166

ABDOMINAL PAIN

general outline corresponds to one type of liver
colic as is seen in cholecystitis due to gallstones
or thickened bile. It is the most frequent type
of liver colic seen.

The symptoms of gallstones depend on the
location of the calculus. Intense pains lasting
several days are peculiar to gallstones in the
gallbladder or cystic duct. This condition will
further be characterized by mild fever lasting
several days, although this fever may be absent.
Leucocytosis is present even after disappear-
ance of the pain or fever. The presence of
a large, tender gallbladder, hypocholia of the
stools and absence of icterus are seen in chole-
cystitis or stones in the gallbladder. Icterus and
hypocholia of the stools occur in these cases if
the common or hepatic ducts are involved either
in inflammation, such as occurs in chronic cases,
with infection or compression from without. If
the stone reaches the common duct, we will find
a very sudden, single, intense, short, colicky
pain around the navel, with an intense or even
total obstruction icterus as early signs. A tem-
porary high fever of short duration with initial
chills may also be present.

If the stone remains in the common duct, the
effect may be variable as follows. First, the
clinical manifestations may consist of moderate
pains localized to the region of the gallbladder,
epigastrium, around the navel, or even to the

STONE 167

left of the midline. Chills and a short, high
fever may also be present. Distinct icterus and
acholia or hypocholia of the stools are usually
present and may regress but very slowly. Itch-
ing is, as a rule, very marked; the gallbladder
is usually small, shrunken, and not palpable.
High leucocytosis and tumor of the spleen may
also be found. The former may be present only
during an attack and disappear in the intervals.
Such attacks recur at irregular intervals, often
following each other so quickly that the icterus
has no time to regress.

Second, the stone constantly hinders the out-
flow of bile, causing chronic icterus and marked
and obstinate itching of the skin. These may
develop without the appearance of pains.

Third, the most common type shows a single,
very severe attack of colic with icterus, chills,
and fever and is followed at irregular intervals
by similar attacks, which are always less severe
in degree. Finally, the icterus and pains are
entirely absent, the former being replaced by
a peculiar ashy color of the skin, and the diag-
nosis will then be based upon the reappearing
chill and fever attacks, the enlargement of the
liver which is nearly always present, urobilin-
uria, and itching of the skin, which is usually a
constant finding in chronic gallstone disease of
the common duct.

The chronic cholelithiasis, which is followed

168 ABDOMINAL PAIN

by hydrops or empyema of the gallbladder, will
be discussed in the chapter dealing with chronic
hypochondrial pain in the right side.

I wish to call attention to the fact that many
cases of stone in the hepatic, cystic and common
ducts cause enlargement of the liver without
any other symptoms. Such a type can be diag-
nosed only after repeated examination and the
finding of this periodic swelling of the liver.

We usually have to deal with a combination
of cholecystitis and cholelithiasis when the clin-
ical picture is typical. We may use the fol-
lowing points to determine whether we are deal-
ing with aseptic stones in the gallbladder or
cholecystitis. In cholecystitis with stone there
are fever, the usual findings on palpation, feel-
ing of soreness or mild pain over the gallbladder
during the intervals between the acute attacks,
and a painful catch in the breath during inspira-
tion. The passage of stones in the feces or the
positive findings on X-ray examination may be
decisive.

In acute cholecystitis or cholangitis without
stone, we may find exactly the same type of
liver colic. This group includes the cholecystitis
caused by typhoid, paratyphoid, colon bacillus
group, or pus-producing bacteria, as in osteo-
myelitis, by carcinoma or tuberculosis of the
gallbladder, and acute syphilitic cholecystitis
with high fever. The diagnosis of the serous or

PHLEGMONOUS CHOLECYSTITIS 169

seropurulent cholecystitis will be made on the
above-mentioned symptoms of liver colic, but
the gallbladder is seldom palpable, as it is cov-
ered by the liver or is shrunken. There may
also be urobilinuria and nucleoalbuminuria. Ty-
phoid cholecystitis will also produce a leuco-
penia. The signs of inflammation will be more
marked if the disease becomes purulent, and this
will be manifested by increase of the pain and
tenderness.

In cases of very severe or phlegmonous cho-
lecystitis, the patient may show the picture of
a localized or very severe peritonitis. The
colicky pains, however, need not be very intense
and may sometimes be found in the epigastric
or in the ileocecal region. The tenderness may
be diffuse, later becoming localized over the
gallbladder region, and the gallbladder itself
may be palpable. It is evident that the history
will be of great value in many cases of this
group.

In typhoid or paratyphoid, the cholecystitis
may appear during the disease or after a long
interval even after a lapse of several years. A
chronically inflamed gallbladder, may, on the
contrary, be a portal of entry for typhoid bacilli
and thus facilitate a chronic typhoid infection
which may later break out into a typical attack
of typhoid. It seems advisable, therefore, in
cases of indefinite infection of the gallbladder

170 ABDOMINAL PAIN

or ducts, especially if the attacks are accom-
panied by diarrhea, to examine the feces for
typhoid or paratyphoid bacilli and to make a
blood examination, Diazo reaction and white cell
count.

The distention of the whole abdomen, which
may occur in liver colic, especially when due to
gallstones or acute cholecystitis, is apparently
due to a reflex paralysis of the bowel or a paral-
ysis situated above a spastic contraction. Pas-
sage of feces and flatus may be absent for many
hours in some cases, and there may be distinct
symptoms of ileus in some very severe cases.
It is worth mentioning that these signs of dis-
tention may precede the attack of liver colic
by several hours. It is possible that this occurs
in those with a special predisposition of the in-
testines, as in a case I have seen of chronic
abuse of tobacco extending for several years.

The acute cholangitis, either intra- or extra-
hepatic, will be diagnosed by the presence of
moderate pains even after the attack of colic
has gone, as well as by the presence of a peri-
hepatic rub, considerable swelling of the liver,
exquisite and continuous tenderness over the
incisura hepatis, icterus of variable intensity
with hypocholia (acholia is only rarely ob-
served), polynuclear leucocytosis, and acute tu-
mor of the spleen. The splenic enlargement is
a common finding in these cases. Of course, we

CHOLANGITIS

must not be satisfied with the mere diagnosis of
cholangitis, but we should try to determine the
underlying cause. It may be secondary to an
acute cholecystitis, to hematogenous or lym-
phatic infection from the intestines, and occa-
sionally to foreign bodies or parasites in the
bowel. Ulcer and carcinoma of the duodenum
at or near the region of the papilla are also
possible causes.

Infectious, inflammatory conditions may
cause liver colic, and the picture may resemble
gallstone colic with many recurrences. If we
are dealing with a single attack of colic with
persisting symptoms, such as icterus, we will
consider the condition as secondary rather than
as primary cholangitis. We will also have to
think of the possibility of a carcinoma of the
gallbladder or cystic duct if we are dealing with
an older person who has an attack of colic for
the first time or an attack after many years
of apparent dormancy; especially if the icterus
appears several weeks after the colic and there
is anorexia and ascites.

In the presence of a cholangitis, we must con-
sider a stone in the common duct or stenosis of
the latter from some other cause, such as car-
cinoma of the duodenum at the diverticulum
or in the head of the pancreas, carcinoma of
the common or hepatic ducts, and gumma or
tuberculosis of the gallbladder.

ABDOMINAL PAIN

Another cause for recurring liver colic is the
presence of adhesions around the gallbladder
or liver with the omentum, stomach, duodenum,
colon, or abdominal walls. These adhesions
are usually acquired, although they may excep-
tionally be congenital. They probably cause
liver colics by torsions or displacements wliich
cause periodic difficulty in the outflow of the
bile into the intestine. High fever or evident
obstruction icterus will point against this diag-
nosis, but slight icterus or mild temperature
may be present. The diagnosis will be based
on the history of a causative factor, the influence
of posture on the pains, and the dependence of
the pains on the fullness of the gastrointestinal
tract or its peristaltic activity. These latter
factors explain the relation to the intake of
food: In cases of dilatation of the stomach or
duodenum; the presence of an enlarged gall-
bladder will point to a compression of the latter;
the absence of an enlarged gallbladder will
speak for adhesions. X-ray may also be of
value in the diagnosis of this condition. It is
evident that the presence of adhesions between
the under surface of the liver, especially of the
left lobe or of the gallbladder to the stomach,
will modify the radiation of the pains in diseases
of the stomach. The radiation of pain to the
right in cases of known or recognized gastric

KCCHJNOCOCCUS CYST

173

ulcer will point to the presence of such ad-
hesions.

The Wasscrrnann reaction and the effect of
luetic treatment will be of great importance in
liver colic of luetic origin which is due to ad-
hesions or to a lues of the liver followed by a
secondary cholangitis.

We must not forget that the liver colics which
are due to adhesions may sometimes be signs
of early malignant disease. Another possible
cause for such a liver colic is echinococcus cyst
of the liver which has perforated into the large
bile ducts with a wandering of the daughter
cysts in the bile passages. The diagnosis will
be based on the history, cystic tumor in the
liver, characteristic fremitus over the cyst, pres-
ence of hooklets or membranes of the cyst in
the stools, eosinophilia, urticaria with the liver
colic, and the specific complement fixation test.

A perforation of a tuberculous gland, more
rarely of a carcinomatous gland ad portam
hepatis into the larger extrahepatic gall ducts,
may produce such an intense colicky attack.
Of course, we can make the diagnosis only when
the existence of such glands is known to have
been present and when these glands produce an
obstruction icterus which slowly increases in
intensity, regresses rapidly with a severe colic,
and is then accompanied by the reappearance
of cholic feces and acute malena.

174

ABDOMINAL PAIN

Liver colic may be due to a real mechanical
obstruction as well as to the infectious causes
mentioned before. Such mechanical obstruc-
tions may be congenital or acquired. The latter
occurs after operations on the bile passages,
as a result of ulcerative cholangitis {typhoid,
coli, tuberculosis and lues) and stones with sub-
sequent scar formation. Other causes are malig-
nant tumors or papillomata of the hepatic or
common ducts or duodenum, carcinoma of the
head of the pancreas, rarely pyloric carcinoma,
chronic pancreatitis, enlargement of the peripor-
tal and retroperitoneal glands, luetic or tuber-
culous foci healed by masses of connective tissue,
chronic luetic peritonitis, compression by tumors
or cysts of the liver, abnormally large gallblad-
der or right kidney, large transverse colon, and
foreign bodies, such as fruit seeds and parasites.

I wish to emphasize the point that chronic
affections must also be considered if a patient
who has previously been in excellent health sud-
denly develops a classical liver colic. Such colics
may recur in some cases and are followed after
some time by chronic obstruction icterus while
the pain regresses or even entirely disappears.

There are two conditions which may produce
liver colic but which cannot be differentiated
from one another. These are aneurism of the
vessels of the gallbladder and the same affec-
tion of the arteries of the liver. We find a

PSKUDOLIVEB COLIC 175

pulsating tumor, systolic or continuous murmur
over this tumor, obstruction icterus, and history
of trauma or infectious disease which may cause
this condition. Aneurism of a gallbladder ar-
tery may also produce a sudden bleeding from
the mouth or rectum. The colicky pains will
be due, not so much to the tumor itself, but
rather to the repeated bleedings in the bile ducts.
Similar bleedings causing liver colic may be
present in angioma of the liver or hemorrhages
into luetic liver tissues.

Cases of parasitic obstruction of the bile
ducts will show eosinophilia, eggs in the feces,
chronic jaundice or icterus of varying intensity,
cholecystitis, or cholangitis with enlargement of
the liver and with, perhaps, eventual clearing
up of the symptoms after passage of the para-
sites either per mouth or rectum.

An abnormally movable or pedicled gallblad-
der may also lead to liver colic.

We must distinguish a group of the so-called
pseudoliver colics from the true liver colic.
The former group includes those cases caused
by stretching or inflammation of the capsule
of the liver, or of primary inflammation of the
capsule. The diagnosis will be simplified by
hearing a perihepatic rub, but we may make the
diagnosis even in the absence of this rub by
noting that the pains appear or are increased
by movement of the diaphragm, as in coughing,

ABDOMINAL PAIN

breathing, or sneezing. These pains are some-
times described by the patients as a stitch in the
side, rurthermore, there is marked tenderness
in the intercostal spaces, lagging of the right
lower chest during respiration, and a catch of
the right upper rectus in inspiration. The diag-
HOsU may be more difficult if fever is present,
as Pick's polyserositis may begin with fever and
liver colic of this nature.

Still more difficult will be the diagnosis of
conditions causing but a single attack of liver
eolie with collapse. Here we must remember
that acute perforative peritonitis in the region
of the porta hepatis resulting from a perforated
gastric ulcer may pfoduce such an attack by the
rapidly developing perihepatitis.

Another cause of pseudohepatic colic with
fever of an intermittent character and short
course is acute purulent or luetic pylephlebitis
of the portal vein, which may be caused by in-
flammation somewhere in the abdomen or infec-
tious process in the bile passages or gallbladder,
or in gallstones.

We must, furthermore, mention thrombosis
of the portal vein or of a vein in a loop of small
intestine. Thrombosis of the portal vein will
cause a rapidly developing ascites with acute
splenic enlargement and the usual signs of por-
tal stasis, such as dilatation of the veins in the
abdominal walls and varices in the oesophagus,

THROMBOSIS OF MESENTERIC TEIN

177

rectum, etc. Thrombosis of a mesenteric vein,
in which ■ local tenderness in the gallbladder
region may he present, will be diagnosed by an
occult or manifest malena, history of a trauma
to the abdomen, a demonstrable inflammation
or ulceration in the small intestine, and condi-
tions in the heart, liver, or portal vein, wliich
may interfere with the circulation in the portal
veins.

Acute yellow atrophy may, in a small number
of cases, cause very intense liver colic, which
may be repeated several times daily. The same
symptom has also been described in phosphorus
poisoning. The diagnosis of the acute yellow
atrophy will not be easy even in pregnant or
puerperal women, as it is just these patients
who are disposed to gallstone attacks. The sub-
acute type of acute yellow atrophy will be
more difficult to recognize, as severe symptoms
such as the marked nervous, toxic symptoms,
marked weakness, apathy, delirium, etc., may be
absent. Only general weakness or dyspepsia
may be complained of for weeks. In addition we
sometimes find an initial enlargement of the liver
which is in contrast to the later shrinkage. Fever
is often present, the spleen is nearly always en-
larged, and there is intense icterus with absence
of hypocholia or acholia in the early stages, as
the resulting icterus in the early stages is not
a result of obstruction in the bile passages.

178 AMBOXTSAL FAJDT

A, symptom which tome seems icijf important
ts the repeated m writing of large mmwh> ^ of bile.
This symptom is of value only if we can exclude

a communication between the *ti ■■■**!! and gall-
bladder or bile ducts. We most search for
Ifficm and tyrosm in the mine, diminution of
urea, and increase in ammonia and bilirubin,
the latter somet im es being seen in crystals. In
the further course, the progressive shrinkage
of the fiver, severe nervous symptoms, and signs
of a severe h emor rhagic diathesis will appear.

Suppuration of the liver itself, either as a
primary solitary or multiple abscess, suppurat-
ing carcinoma or gumma, echinococcus cyst or
angiamo, or the result of ascaris infection all
produce febrile liver colics. In such suppura-
tive conditions, we will find local tenderness,
enlargement of the liver as a whole, but with
increase in size at some particular place, tumor
of the spleen, moderate leucocytosis, and, occa-
sionally, icterus. The cause of the suppuration
may be determined by serological or X-ray ex-
amination as well as by the symptoms which
are rather characteristic in these cases.

Liver colics in syphilis of the liver may not
only be caused by the complicating cholangitis,
cholecystitis, or perihepatitis and suppuration
of a gumma, but may be due to the interstitial
luetic hepatitis, even in the absence of suppura-
tion. It is important to notice that the enlarge-

WANDERING LIVER 179

ment of the liver is especially marked in the
left lobe, or a part of the liver near the gall-
bladder may become enlarged, as sometimes
occurs in gallbladder disease. The consistency
is increased, the surface is smooth or knobby,
the spleen is usually enlarged, and there are
intermittent and irregular fever and albuminu-
ria. The pains in interstitial hepatitis may be
due to the accompanying perihepatitis or to
rupture of a syphilitic vessel of the liver with
the resulting bleeding into a bile duct, as occurs
in infarct of the liver. Acute malena will be
present in bleeding into a bile duct and in infarct
of the liver.

In cases of carcinoma of the liver, colicky
pains may be due, as already mentioned, to
suppuration of the carcinomatous nodule, sec-
ondary perihepatitis, or an increased tension of
the capsule if the growth of the tumor is very
rapid.

A wandering liver may also be accompanied
by intense, colicky pains in the right hypochon-
drium, especially upon quick or sudden move-
ments of the body. The diagnosis will be made
on the abnormally deep position of the liver,
especially the upper and posterior borders, and
on the abnormal mobility of the organ.

Hemolytic icterus may also be accompanied
by colicky or pressing pains which recur and
are usually mild, although they may be severe

180

ABDOMINAL PAIN

and located in the region of the liver incisura
or over the whole liver region. As a rule, we
find at the same time colicky pains in the left
hypochondrium which may even be more marked
than those in the right hypochondrium. The
liver and spleen are enlarged, the anemia and
the icterus may vary in intensity from time to
time, and bilirubin may be absent, or present
only in traces in the urine, while urobilin and
urobilinogen may be very marked. The blood
serum shows a more or less marked bilirubin
reaction. There is hypercholia of the feces and
often diarrhea. Bradycardia and itcliing are
usually absent. Very characteristic is the rapid
and striking reduction in the number of erythro-
cytes during the attacks, which may also be
accompanied by the clinical signs of acute ane-
mia, such as weakness, faintness, and cerebral
irritation. We will also have to examine the
reaction of the red blood cells with hypotonic
salt solution and also of autoagglutination. The
history of the same illness in the family is of
value. The painful attacks may closely resem-
ble real gallstone colic and are due to the thick-
ened bile or concretions. In other cases, the
abnormally large destruction of red blood cells
may cause the pains. The pains may persist
or even increase after extirpation of the spleen,
so that we are forced to believe that this is an
affection of the entire hemolytic system, among

HEPATIC NEUBALOIA

which the star cells of Kupfer may be con-
sidered.

If we observe a case of liver colic without any
ibjective findings, we should hesitate to make
the diagnosis of hepatic neuralgia, as all these
cases which have come to my attention have
eventually turned out to be due to gallstones.
More important are those cases described as
liver crises of tabes. These attacks are some-
times accompanied by a slight attack of icterus
and are perhaps explained by a cramp of the
muscle of the bile ducts. Another nervous con-
dition which must be considered is abdominal
migraine, in which the attacks may sometimes
resemble a real gallstone colic, but in which a
family history will be of importance. The oc-
currence of typical migraine in the head, alter-
nating with such attacks as here mentioned,
may be seen. Besides the absence of all local
and general findings and the presence of normal
urine, I think that it is of importance to remem-
ber that migraine ends, as a rule, with vomiting,
a phenomenon which does not occur in gallstone
colic in which the vomiting has little or no effect
on the pain. Deep inspiration, which increases
the pain in gallstone disease, will not have any
influence in these cases. The effect of migraine
treatment may be of some help in these cases.

So far we have discussed pseudoliver colic
due to conditions of the liver itself, but we shall

182

ABDOMINAL PAIN

now consider those cases due to extrahepatic
conditions. In the first place, we must mention
duodenal ulcer, especially cases which cause
periodic attacks. Icterus may be present and
may be due to an intercurrent affection of the
gall ducts or stenosis of the papilla of Voter
by a callous ulcer. Colicky pains in the liver
region may also be due to a stenosis of the duo-
denum following healing of an ulcer in this
region. The same may be true in gastric ulcer,
pyloric stenosis from some other cause or ad-
besions, especially acute perigastritis following
an ulcer of the stomach or duodenum. Acute
lymphadenitis at the porta hepatis from these
peptic ulcers may also cause liver colic.

Diaphragmatic pains on the right side may
be due to a primary diaphragmitis or may be
secondary to a basal pneumonia. This may be
accompanied by a slight degree of icterus and
urobilin and bilirubin in the urine. The pres-
ence of the tender points along the phrenic
nerve and the absence of tenderness over the
liver will distinguish this form of pain from
hepatic colic. The same may be true of a basal
pneumonia of either side, but we must also re-
member that a disease below the diaphragm
may also cause a pneumonia by extension along
the various routes.

It may be important to mention that the first
symptom of carcinoma at the pylorus may be

183

such a pseudohepatic colic which may sometimes
appear at night and recur periodically for weeks
before any symptom referable to the stomach
appears.

We must bear in mind, in all cases of hypo-
chondria! pain on either side, the possibility of
a retroperitoneal condition such as retroperito-
neal sarcoma.

The clinical picture of a liver colic may also
be imitated by disease of the pancreas, such as
acute or chronic pancreatitis, pancreas necrosis,
stone, or, more rarely, pancreatic cysts. In all
these cases the functional tests will be of very
great importance, but we must also remember
that a complicating pancreatitis may occur in
cholecystitis or real gallstone disease, so that
alimentary glycosuria in gallbladder or gall-
stone disease must call our attention to the pos-
sibility of this condition.

The colon may simulate hepatic colic in cases
of ulcer at the hepatic flexure, as may simple
intestinal colics due to fecal masses in the colon,
carcinoma of the hepatic flexure, especially if
adherent to the gallbladder, and carcinoma any-
where in the colon distal to the hepatic flexure,
in which condition the pain is caused by disten-
tion by the accumulated gases which are unable
to pass the obstruction.

Other conditions which may cause such symp-
toms are colitis and pericolitis, especially the

ABDOMINAL PAIN

latter if localized at the hepatic flexure, or if
the pericolitic exudate extends toward the liver.
Icterus, acute splenic tumor, and herpes may be
present in pericolitis, but the diagnosis may be
made on careful palpation after the acute symp-
toms have disappeared. At this time we may
find a fixed, sausage-shaped tumor extending
from the costal arch to the iliac fossa?, which
may produce borborygmi during palpation, es-
pecially if the condition is regressing. Further-
more, the history of a previous intestinal affec-
tion, to a certain extent the presence of indican in
the urine, and the absence of hepatic enlargement
all speak for pericolitis or colitis of the ascend-
ing colon.

For the assumption of adhesions, it seems
to me of importance that the very severe
colicky pains appear five to six hours after
meals, often also during the night, and some-
times upon bodily motion. The finding of local
tenderness over the colon is of importance. We
must remember the peculiar qualities of a colonic
colic. These are the wave-like character, short
duration of the waves, which are a few minutes
long at the most, gurgling in the abdomen,
termination of the colic on passage of flatus or
feces, and the fact that the colic may be pro-
voked by a gas-producing diet. Chills and fever
are, as a rule, absent unless there are ulcerations
of the colon, as from a carcinoma, but even in

APPENDICITIS— PKRI APPENDICITIS

185

these cases the fever is not connected with the
attack of colic, but is also present during the
intervals. The pains in disease of the colon
may also travel from place to place along the
colon and may be relieved by local pressure
or massage. I also wish to emphasize the great
value of the X-rays in the diagnosis of most of
the diseases of the colon which have been dis-
cussed.

The acute appendicitis and periappendicitis
need special discussion. Icterus may be present
in a certain number of these cases, both severe
and mild. This icterus may be due to sepsis,
toxic affection, or purulent infection of the liver,
accompanying purulent cholangitis or, perhaps,
intestinal paresis with consequent hindrance to
the outflow of bile. The icterus in simple ap-
pendicitis may be due to toxic sepsis and may
be a sign of necrosis of the appendix. The
icterus may in expectional cases be in the nature
of a primary catarrhal jaundice with secondary
affection of the appendix.

The pains in appendicitis may occasionally
be localized under the right costal arch, more
commonly midway between the gallbladder and
ileocecal region, and may radiate upwards to
the right. We must remember that the appen-
dix may be turned upwards or may be displaced
upwards in pregnant women or as a sort of
congenital anomaly. The latter condition is

186 ABDOMINAL PAIN"

caused by a failure of the appendix to descend
from its embryonal location under the liver. It
is evident that in such conditions one may easily
make an incorrect diagnosis, since chills, fever,
vomiting, and even icterus may be present. The
latter may be due to a compression of the large
bile ducts by the exudate. This congenital an-
omaly may be suspected when we observe a sink-
ing in of the abdomen over the normal cecal
region, but is ruled out if we can palpate the
cecum in its normal place. A tympanitic area
between the lower border of the liver and the
tumor mass speaks for a periappendicitis.

In some cases of an enlarged gallbladder, tym-
pany may be found between the liver and tumor
if the colon is interposed between them. I have
seen cases in which this phenomenon was con-
stantly present and was due to fixation of the
colon by adhesions in the above-described posi-
tion. In addition to the shape of the tumor,
the sequence of the appearance of symptoms
will be of value. In involvement of the appen-
dix, the pain is the initial symptom and is soon
followed by vomiting and fever. In chole-
cystitis, however, the vomiting occurs late if at
all. The rectal examination will be of partic-
ular importance in these cases, the rigidity of
the rectus muscle will not be so much restricted
to the upper portion as in gallbladder disease,
while the abdominal reflexes of the middle and

BETBOCECAL APPENDICITIS 187

lower parts are absent. Pronounced and con-
stant indicanuria is rarely present in disease of
the gallbladder, while it is quite a constant find*
ing in appendical affection. Enlargement of
the liver should be used only with caution as a
diagnostic sign.

High retrocecal appendicitis may also imitate
acute gallbladder disease by producing a severe
colicky attack with vomiting and fever of vary-
ing intensity, and with the pains in the anterior
and posterior liver regions. Deep inspirations
increase these pains; there are slight traces of
icterus and some albumin in the urine, and symp-
toms of acute nephritis may follow. The pa-
tient also has exquisite tenderness in the region
of the incisura of the liver, with hyperesthesia
of the skin in this region, lagging or absence of
respiratory movement of the right lower chest,
polynuclear leucocytosis, and signs of a general
sepsis. The rigidity is, as a rule, in the entire
right rectus muscle but may be less marked in
the lower part. All the abdominal reflexes of
the right side are absent, but, rectally, we will
always find a tender point corresponding to the
appendix. Dysuria may also be present. The
condition seems to be more frequent in men than
in women. A similar picture may be found in
actinomycosis of the appendix, followed by
spread into the liver.

Another complication of a primary appendi-

188 ABDOMINAL PAIN

citis which may be confused with gallbladder
disease is an involvement of the portal vein.
Thrombophlebitis of the mesenteric vein or of
the retrocecal veins which go to the vena cava
may also give rise to symptoms which may be
mistaken for gallbladder disease. The involve-
ment of the portal vein is not a rare complica-
tion and may lead to liver abscess. We may
suspect portal vein disease if we observe that
tenderness in the liver occurs about twenty-four
hours or later after the appendical attack.

We sometimes find, after purulent appendi-
citis or operation for this condition, the devel-
opment of icterus which is due to acute paren-
chymatous hepatitis, and which is followed by
acute yellow atrophy of the liver, a condition
which is caused by sepsis of the liver or perhaps
the effect of chloroform on the liver.

In regard to the differentiation Detween a
primary pericholecystitis and periappendicitis,
which may be a result of the first, I wish to
refer the reader to a chapter dealing with
these conditions.

Another condition in which the patient may
complain of very severe colicky or more contin-
uous, throbbing, or boring pains in the gall-
bladder region is in perforation of the gall-
bladder into the colon, stomach, or duodenum,
and more rarely of these organs into the gall-
bladder. The cause of this perforation is usually

GALLSTONE 189

a necrosis caused by a gallstone or carcinoma.
This kind of perforation may be made possible
by adhesions or by local peritonitis between
these organs. The diagnosis will be based on
the pains and fever, local tenderness, local peri-
tonitic symptoms, general septic appearance,
the appearance of diarrhea with bile or even
pus after a preceding acholic stool, gross bleed-
ing or malena in the stools, and abrupt regres-
sion of the infectious symptoms. Tenesmus
may also be present in perforation into the
colon.

Organs distant from the colon may produce
colics which may be mistaken for primary liver
colics. A wandering kidney, for instance, may
be located near the porta hepatis and produce
a compression of the common duct of the liver
with resulting colic and even icterus. In such
cases, the tumor of the kidney may be mistaken
for the gallbladder, especially in cases of inter-
mittent hydronephrosis where the kidney is ad-
herent to the liver. The true nature of the
condition will be recognized if the pain disap-
pears after reposition of the tumor in the renal
region; the normal kidney dullness in the renal
region may be absent, the colics will not be noc-
turnal, as they are in gallstones, and there may
be albuminuria or red cells in the urine after
palpation of the tumor. In cases where the
usual physical methods are not sufficient, we

190 ABDOMINAL PAIS

may employ the X-ray with a metal urethr al
catheter in place or after filling the pelvis with
collargol or potassium iodide solution. We must
not forget that a combination of wandering kid-
ney or nephroptosis and cholelithiasis is not at
all uncommon.

A genuine gallstone colic with all its typical
symptoms may be mistaken for a renal colic
when the kidney is in an abnormally high po-
sition. I have seen cases in females only where
the patients were suffering from gallstone colic
but also had a constant desire to urinate with-
out being able to do so. The pains may even
radiate along the ureters into the bladder or
labia. This condition is recognized by the fact
that pain on deep percussion over the kidney
region is less marked than over the liver region
anteriorly, and by the presence of the other
usual symptoms of gallstone disease.

Not only a displaced right kidney, but one
in its normal position may produce pains which
are located in the gallbladder region. Here,
the pain and tenderness are located deeply
rattier than immediately behind the right costal
arch. We also have the usual physical and
urinary findings associated with renal disease*
In cases of combined gallstone and renal dis-
ease, the patient may experience the attack of
subsequent and, later, renal colic after a gall-
stone colic has already set in.

HYPOCHONDRIA!. PAINB 191

Another possible combination of gallstone
and renal colic may be seen in perforation of
a gallstone into the kidney pelvis, especially if
there was a pre-existing pericholecystitis. It
may be possible to find that a gallstone has
passed along the urinary tract.

I wish to point out particularly that an af-
fection of the right kidney may be associated
with sudden colic or more or less continuous
pain in the gallbladder region. These are cases
of inflammation or even suppuration of the fatty
kidney capsule, not involving the posterior sur-
face, but affecting only the anterior and sur-
rounding tissues. In all the cases that I have
seen, the patients complained of pain in the
gallbladder region, the pains and tenderness
being very deep and not directly behind the
arch; the skin in the lumbar region was hyper-
algesic, and there was a tenderness on deep
percussion over these regions. There was ab-
sence of hepatic findings, and there were no
red cells, bacteria, or albumin in the urine. A
history of some previous suppuration as furun-
culosis, etc., will be of importance.

Finally, I wish to mention that hypochondrial
pains on the right side may be produced by
tumors, especially by hypernephroma of the an-
terior surface of the kidney.

We must also bear in mind the possibility of
the female genitalia as causing pains similar

192

to liver colic These are ovarian tumors or
long pedicled tumors of the uterus, such as long
subserous myomata and especially the extra-
uterine pregnancies. The difficulties in these
cases are very great, as we know that the first
attack of cholelithiasis often appears during the
first pregnancy.

Pseudoliver colic and even icterus may be
present in cases of chronic lead poisoning, es-
pecially in those cases in which there was pre-
vious disease of the gallbladder. These attacks
of apparent liver colic in lead poisoning may be
due to atypical localization of the pains or to
the blood destruction, namely, hemolysis, just
as in cases of hemolytic icterus.

In conclusion, I wish again to emphasize the
point that recurring colics in a cholelithiasis
need not always be due to recurring gallstone
trouble, but may be due to some other cause, as
adhesions, perforations, etc.

Acute, Continuous Pain in the Right Hypo-
chondrium, Over the Gallbladder Region

Not all the diseases of the bile ducts and
gallbladder cause colicky pains, as they may
also be boring, burning, and throbbing in char-
acter, or they may be described as a painful ten-
sion in the gallbladder region. The pains ap-
pear suddenly and remain as a continuous type
for the remainder of the attack. This occurs

especially in acute inflammation of the gall-
bladder or of its peritoneal covering. All the
conditions which have been mentioned as pro-
ducing liver colic may produce continuous pain
instead of colic. I wish to point out one con-
dition of the gallbladder — the rare torsion of
this organ which is characterized by a suddenly
beginning, intense pain in the gallbladder, local
tenderness, constipation, leucocytosis, sometimes
vomiting, and the formation of a palpable tumor
in the gallbladder region. This tumor may be
pear-shaped, or, if the gallbladder lies rather
transversely, it may be kidney-shaped and may
then be mistaken for a wandering kidney or
hydronephrosis.

Rupture of the gallbladder is more common
after it has undergone inflammation. It then
ruptures in a previously walled-off sac in most
cases. In this condition we may obtain a his-
tory of previous attacks of pain in the gallblad-
der region, with a sudden increase in intensity,
with fever, and sometimes with an initial chill
and collapse. The local abdominal rigidity,
pain, and tenderness will be very marked. Later,
there is a palpable tumor which is also painful,
is seen in the gallbladder region, and corre-
sponds to the pericholecystitic abscess. The
fever will continue, chills and peritonize symp-
toms will perhaps appear, and the pulse will be
markedly slow as a result of absorption of bile.

1M ABDOMINAL

The perforation into the free peritoneal cavity
is, as a rule, characterized by wandering of the
pains towards the navel after a few hours and
collection of the exudate in the ileocecal region.
The condition may then be mistaken for acute

We must furthermore consider acute pyle-
phlebitis of the portal vein, acute thrombosis of
this vein, and ascending thrombosis of the hepat-
ic veins resulting from a thrombosis of a mesen-
teric vein. In acute portal thrombosis we will
find very sudden and intense pains, sometimes
diffuse and sometimes localized over the liver
region, vomiting, bloody diarrhea, acute meteor-
ism, acute tumor of the spleen, and strikingly
rapid development of ascites which quickly re-
appears after puncture. Icterus and urobili-
nuria are absent as a rule, but the absence of
this urobilinuria may be used in excluding this
vein affection as arising from a liver or gallblad-
der disease. In cases where there is only inflam-
mation of the vein and no obstruction, we find
intermittent fever, chills, local tenderness ad por-
tam hepatis, general sepsis, and leucocytosis or
leucopenia. These findings will make us think
of this condition in the presence of a causative
factor.

In addition to thrombosis of the portal vein,
we must also remember that sudden, intense
pain in the liver region may be caused by throm-

GASTBIC, DUODENAL CONDITIONS 195

"bosis of the hepatic veins or the vena cava in-
ferior below the diaphragm. Hepatic vein
thrombosis will be characterized by a marked
passive hyperemia of the liver and its enlarge-
ment with signs of portal stasis. Thrombosis of
the vena cava will show the same symptoms with
the addition of edema in the lower extremities
and lower part of the body.

In the presence of an endocarditis, we must
think of the rare possibility of an embolus in the
liepatic artery or one of its branches, which may
be followed by infarct or perihepatitis.

Actinomycosis of the liver presents a picture
of sepsis apparently arising from the liver, but
the course is not stormy.

A wandering liver may also be the cause of
such pains, and the pains may be due to the in-
terposition of the colon between the liver and the
diaphragm. This condition is characterized by
a zone of tympany over the liver dullness and
by abnormal location of the colon as shown by
X-ray examination.

Among the gastric and duodenal conditions
which cause this pain are rupture of the duo-
denum, perigastritis, periduodenitis, and peri-
appendicitis. In cases of acute periduodenitis,
we have two valuable indications: the patient
complains of pain in the back at the level of the
lesion, with hyperesthesia of the skin over this
posterior area, and there is shortening of the

190 ABDOMINAL PADT

distance between the tip of the tenth rib and
the spine of the ilium. Perigastritis, periappen-
dicitis, and abscess around the duodenum will
present great difficulties in the absence of a his-
tory of disease in these regions.

We must add that such pains may also be
caused by disease of the pancreas, tumors be-
hind the liver, disease of the transverse colon,
distention by gas of the hepatic flexure, which
may be a result of general flatulence or moderate
stenosis, disease of the periportal glands, wan-
dering kidney which is fixed at the porta he-
patis, and such renal affections as pyelitis and
renal infarct. In the renal infarct, the pains
may be accompanied by chills and vomiting, and
the liver may be tender as a result of a weak
heart. In these cases, the tenderness of the liver
may lead to difficulties in the diagnosis.

Apoplexy into the perirenal tissues must also
be mentioned as a cause for this type of pain. The
symptoms are very much like those of gallblad-
der disease, as there may also be intense initial
pain with collapse and an indistinct tumor in the
right hypochondrium corresponding to the peri-
renal hematoma. The right hypochondrium may
be tender and bulging. The liver is pushed for-
ward and appears enlarged as a result of this
displacement. Icterus may be present and is
hematohepatogenous and not obstructive in
origin.

-HYPOCHONDHIALGLA

The cardiac conditions which may cause this
pain are atypically located angina pectoris and
rupture of the right auricle.

We must also mention two infectious diseases
which jnay imitate liver colic. These are ma-
laria and recurrent fever. Pain in the gallblad-
der region with tenderness, hyperesthesia of the
skin over the liver and in the back, and moder-
ate enlargement of the liver may be seen in
malaria. The finding of the parasite in the
blood and the effect of quinine may give the
proper clue.

Chronic Continuous Hypochondrialgia Dextra
in the Gallbladder Region

Any of the diseases of the liver, bile ducts,
and organs in the immediate vicinity of the liver
may cause this type of pain if the course as a
whole is mild. A common cause of this type of
pain is hydrops of the gallbladder — a condition
which may also exist without pain. Of value in
the differentiation from empyema or cholecys-
titis are the absence of marked tenderness, fe-
ver, increased pulse rate, and leucocytosis. The
cause of the hydrops may be stone or carcinoma
of the common duct. If a patient who never
previously suffered from liver colic shows a
hydrops of the gallbladder in the later course of
life, we must suspect an incipient carcinoma.

On the contrary, a history of repeated colicky

ABDOMINAL PAHC

attacks will call attention to the possibility of
stone in the bile ducts. The general symptoms,
such as dyspeptic complaints, anorexia, cachexia,
progressive course, and icterus with ascites, will
point to carcinoma. More common than hy
drops as a cause for such pains are pericholecys-
titic adhesions. Here we find that the pains are
often increased by intake of food, movement of
the bowels, lifting of heavy weights, or brisk
movement of the body. The patients are some-
times compelled to assume certain attitudes in
order to obtain relief. We occasionally find that
the pains are increased upon raising the right
arm, a phenomenon which is due to adhesion of
the right diaphragm with the abdominal wall.

Diffuse Pain Over the Right Hypochondrium

If a patient complains of pains which last for
various periods of time and which are not local-
ized to the gallbladder region, but are also dif-
fuse over the right hypochondrium, we must first
consider all the affections which may cause en-
largement of the liver with resulting stretching
of the capsule. The pain results from the
stretching of the nerves, which are present in
great numbers in the capsule. Diabetes may
cause active hyperemia of the liver with conse-
quent stretching of the capsule nerves.

Another cause may be non-suppurative, paren-
chymatous hepatitis from infectious or toxic con-

HEPATITIS 199

ditions, sometimes combined with very intense
pains, fever sweats, leucocytosis, and dyspeptic
complaints. Gout, either before or during an
attack, may cause swelling of the liver with
urobilinuria. Polycythemia rubra and hemolytic
icterus may also cause this pain. The pain may
be due to the thickened bile obstructing the. bile
ducts in hemolytic icterus. In alcoholic cirrhosis,
the pain is due partly to the regeneration and
partly to the cholangitis. We must also consider
passive hyperemia of the liver, all chronic in-
flammatory or neoplastic processes, echinococ-
cus, perihepatitis, which may be an early sign
of a tuberculous peritonitis still localized,
chronic intrahepatic pylephlebitis, and subphre-
nic inflammation on suppuration. In regard to
the latter condition, I wish to emphasize the point
that it may be the only symptom of a chronic
appendicitis for a long time. The autopsy in
these eases need not necessarily show the pres-
ence of small hepatic abscesses, as we may find
only a round cell infiltration around the intra-
hepatic tributaries of the portal veins. In this
connection, we must remember that an actino-
mycosis may be the cause of a chronic appen-
dicitis.

Furthermore, we must mention stenosing or
obstructing processes of the large bile ducts and
also hypertrophic cirrhosis or simple catarrhal
irus. The liver is more tender on percussion

200 ABDOMINAL PAIN

in the midline than elsewhere, as it is exposed
more in this region than anywhere else.

Passive hyperemia of the liver may cause pain
or oppression in the epigastrium, and these may
be the first and only signs of cardiac insufficiency
in acute or chronic heart disease. This may be
seen in diphtheritic myocarditis in which the epi-
gastric distress may be the only symptom of the
acute infectious myocarditis. Intermittent ex-
acerbations of this chronic epigastric pain may
be due to intrahepatic thrombosis. Passive hy-
peremia of the liver may also be present as a
result of abdominal plethora with or without
adiposity and where there is no weakened heart.
In some of these cases, the abdominal plethora
may be due to beginning sclerosis of the splanch'
nic arteries, in other cases to lack of activity of
the abdominal walls, to storing up of fat in the
abdomen, and to functional weakness of the dia-
phragm. Incipient sclerosis of the splanchnic
arteries may cause an oppression in the epigas-
trium, as already mentioned, but may also cause
a sensation of fullness in the stomach, flatulence,
and tendency to constipation. We find at least
some increase in the blood pressure, some hyper-
trophy of the left ventricle, and sometimes scle-
rosis of the peripheral blood vessels.

If the patients say that this pain in the right
hypochondrium appears especially in the upright
position, we must consider ptosis of the liver,

INTERCOSTAL NEURALGIA

wandering liver, or pedicled tumor of this organ.
We must remember that the reason for pain in
the hypochondrium, either left or right, may be
in the skin, ribs, or intercostal nerves as well as
in the underlying organs.

Intercostal neuralgia, although usually bilat-
eral, may occasionally be unilateral, as in tabes
or spinal tumor. The abdominal muscles, in-
tercostal muscles, diaphragm at the arch or
oblique abdominal muscles may be the seat of
pain. This may be seen in recurrent fever or
when the patient has weak walls. In these mus-
cle pains we find tenderness upon pinching of the
muscle and but little over the incisura, and the
pain has no relation to deep breathing. Tender-
ness of the intercostal muscles may show that the
seat of the pain is in these structures. Diaphrag-
matic pains may be due to overstraining of this
muscle, as in severe cough, or in infection, as in
trichinosis, and rarely by adhesions of the dia-
phragm to the kidney. We must also consider
affections of the subperitoneal tissue such as I
once saw in a case of subperitoneal suppuration
in the right hypochondrium, following a subpleu-
ral suppuration resulting from a tuberculous
sixth rib.

It is also evident that any condition which di-
minishes the intraabdominal space in the liver
region may cause this type of pain. Such condi-
tions are a marked kyphoscoliosis with the con-

202

ABDOMINAL PAIN

vexity to the right side or retroperitoneal tumors
behind the liver.

I wish to point out that any disease which
may produce pain in the right hypochondrium
may do so in several different ways. For ex-
ample, typhoid fever may cause such a pain by
development of typhoid cholecystitis or any other
condition of the liver or bile ducts, periostitis of
the lower ribs, waxy degeneration of the upper
abdominal muscle, pleurisy, etc

Pain in the Right Ileocecal Region

Colicky Pains in the Ileocecal Region

Just as our first thought in colicky pains in
the gallhladder region is of disease of the gall-
bladder, so must our first thought be of the ap-
pendix in the presence of colicky pains in the
ileocecal region.

The acute appendicitis which is usually com-
bined with periappendicitis is, as a rule, charac-
terized by sudden, intense, but rather continu-
ous pains. Colicky pains are comparatively rare.
Real colicky pains will make us think first of
appendicular colic, which may be an expression
of a real stenosis colic or of adhesions. It is of
importance to know that such adhesions may be
present even when the primary affection of the
appendix is only moderately developed. As pre-
monitory symptoms before an attack we may find
general malaise, constipation, dyspeptic com-
plaints, and, in rare instances, diarrhea.

The chronic appendicitis and adhesive appen-
dicitis may remain dormant until an appendicu-
lar colic develops which is due to the adhesions.
Such colics have the tendency to recur at va-
riable intervals. The manner of production of

204 ABDOMINAL PAIN

these adhesion colics is the same as colic produced
anywhere else in the intestine, namely, by limi-
tation of its mobility, kinking, or displacement.

If we find a colic for the first time in the ileo-
cecal region, the following points will aid us in di-
agnosing acute appendicitis. The appendix may
sometimes be palpated as a cylindrical, circum-
scribed, tender body or mass of exudate. This
mass of exudate may vary in size and shape. It
is often sausage-shaped, with the long axis par-
allel to Pouparfs ligament. It is usually fixed,
dull, or dull-tympanitic on percussion and is very
tender on pressure except where there is a peri-
appendical exudate, in which case the tender-
ness is not so marked. It is easier to palpate
when the hip joint and knees of the patient are
flexed. There is also lagging of the ileocecal
region of the abdomen during respiratory move-
ment. The patient keeps the right thigh flexed
on the abdomen, there is pain when we pull the
spermatic tord on the affected side, and the tem-
perature per rectum is abnormally higher than
that in the axilla. We will not be able to feel
the appendix in patients in whom the intestines
in this region are filled.

Other points which require attention are ten-
derness on palpation or percussion over McBur-
ney's point and lower psoas muscle, provocation
of pain by active contraction of this muscle or
of the abdominal muscles, hyperesthesias of the

COLIC IN ILEOCECAL REGION 205

skin, sometimes radiation of the pain to the right
lower extremity or even to the right testicle, nau-
sea, often vomiting, constipation, rarely diarrhea,
dysuria, which may be quite marked, fever, in-
ability to rest on the left side, and tenderness by
rectal and vaginal examination in the direction
of the appendix. In some cases, especially in
marked gangrene of the appendix, we find a di-
lated and flaccid rectum caused by a paresis of
the intestine. This symptom is very valuable,
as we find only moderate tenderness in the ileo-
cecal region in these cases. The condition will
be characterized by frequent pulse rate, com-
paratively low or absent fever, dry tongue, ashy
face, and meteorism. There is also pain m the
iliac region when we attempt to elicit Kernig'a
sign.

This group of symptoms and the characteris-
tic sequence in which they appear, namely, first
pain, then nausea, vomiting, and then fever, will
enable us to distinguisli between appendicular
colic and simple intestinal colic, for which it is
sometimes mistaken.

In the senile, there may be only diffuse ten-
derness and meteorism without any special lo-
calization of the symptoms to the appendical
region. There is, however, a picture of severe
illness, rapid pulse, and only slight fever. The
rectal and vaginal examination will be of some
help.

206 ABDOMINAL PAIN

The differential diagnosis of appendicitis with
recurring colicky attacks and other diseases caus-
ing similar attacks will he discussed in the chap-
ter on recurrent colicky pain. I do wish to dis-
cuss here two conditions in this connection. The
first is mucous colitis, a condition which is often
associated with chronic constipation and result-
ing appendicitis, and which may occasionally set
in with acute pain, nausea, vomiting, chiUs, and
local tenderness in the ileocecal region, so that it
may easily confuse us. The same may he true
of catarrhal or phlegmonous colitis which in-
volves the ascending segment. The difficulties in
the differential diagnosis will be great, as we
know that diarrhea, even bloody in character and
of septic origin, may occur in appendicitis.

The bloody, mucous, or purulent diarrhea may
also be due to a perforation of the appendix into
the colon. The presence of a large quantity of
mucus in the stools speaks rather for colitis than
for appendicitis. The leucocytosis in colitis
hardly reaches more than twenty thousand. The
most important point is the presence of tender-
ness along the ascendens of the colon rather than
at one point. Such a colitis may, however, be
followed by a secondary appendicitis. Sig-
moiditis or perisigmoiditis may also produce pain
in the ileocecal region either by reflex action, ad-
hesions, or compression of the cecum by the dis-

SIMPLE INTESTINAL COLIC

tended sigmoid. The same is true of similar
affections of the small intestines.

Simple intestinal colic shows complete absence
of pain during the intervals, while appendicitis
is, as a rule, accompanied by pains of some de-
gree even during these intervals. These inter-
val pains feel like fullness, flatulence, and pres-
sure in the ileocecal region. Furthermore, these
colics are relieved by an enema or carminatives,
while the same measures have very little effect
in appendicitis. Such a colic may occur in cecal
distention resulting from chronic or spastic con-
stipation or any form of chronic stenosis. The
pains in these cases also show a wandering char-
acter and are relieved by extension of the thigh,
contrary to what occurs in appendicitis. We can
sometimes find the spastic condition in the ileo-
cecal region or perhaps learn that pain is pres-
ent at the same time in the left iliac region. The
sphincter ani may also be spastic, and the rectal
findings will be negative in all other respects.

Local pains in chronic constipation need not
necessarily be colicky in nature. Local tender-
ness, flatulence of the small bowel, and dyspepsia
may be caused by a ptosis of the ileum into the
pelvis or by kinking, as in Lane's disease. The
fact, however, that the pains and tenderness do
not remain definitely localized, but finally wander
along the colon, together with the presence of
eosinophiles in the stools in mucous colitis may

208

ABDOMINAL PAIN

clear up the diagnosis. Furthermore, patients
with mucous colitis have intervals of complete
freedom from symptoms, a condition not ordi-
narily found in appendicitis.

The second condition is volvulus of the cecum
and ascending colon before it becomes perma-
nent. It may cause colicky pains in the ileocecal
region for one or two days. There are the usual
signs of intestinal obstruction in these cases, with
a markedly inflated condition of this part of the
bowel. Peristalsis may even be present, but there
are no signs of peritonitis.

Stones in the kidney or ureters may also cause
colicky pains in the ileocecal region, often with
chills and vomiting, but as a rule without fever.
This localization is found where there is an in-
carceration of the stone in the ureter, or if the
radiated pain in stone of the right kidney is more
severe than the pain at the actual seat of the
trouble. Rigidity of the abdominal wall may be
present, as well as tenderness in the ileocecal
region. Upon close examination, we find that
the tenderness is not as strictly localized as in
appendicitis, but that it is also present more lat-
erally and higher up. The ureter itself may also
be palpable as a vague cylindrical body, which,
however, will not lie on the psoas as in appendi-
citis, but will be rather medial to this muscle.

The tenderness of the psoas is localized chiefly
to its upper part, and if there is tenderness in

KTJMfEY COUC 209

the lower part, it is not so sensitive as the up-
per portion. The infrequent tenderness of the
lower part of the psoas in these cases is seen in
involvement of the entire ureter or when such
complications are present as pyelitis, nephro-
ptosis, hydronephrosis, etc. The local tenderness
in renal stone is constant, while the tenderness
in appendicitis may change its position somewhat
to the left. Tenderness on deep percussion over
the kidney may be present, and the pain may
radiate to the right testicle. This organ, how-
ever, is not tender in appendicitis. It is impor-
tant to find some laked blood cells and albumin
in the urine in these kidney cases.

The differential diagnosis between retrocecal
periappendicitis and kidney colic will be difficult
in spite of the above-mentioned symptoms, espe-
cially in the presence of a complicating parane-
phritis posterior with hematuria or hemorrhagic
nephritis. Fever and neutrophilic leucocytosis
or leucopenia speaks for appendicitis, while ten-
derness of the right testicle is a safe criterion of
renal disease and is absent in retrocecal disease.
Finally, we must make use of the X-ray and ure-
teral examination.

These two conditions may co-exist either as a
result of extension of the appendical inflamma-
tion to the periureteral tissue with consequent
compression of the ureter, or as a result of ex-
tension of the infection via the lymphatics.

210

ABDOMINAL PAIN

The assumption of the existence of a pyelo-
nephritis or acute pyelitis on the right side will
be supported by the findings in the urine, Ieu-
cocyturia and bacteriuria, epithelial cells from
the renal pelvis, tenderness on percussion of the
renal region, hyperesthesia of the skin in the right
lumbar area, and tenderness along the ureter to
the right of the navel or corresponding to the
upper part of the ileopsoas muscle. We must
always think of the possibility of such a pyelitis
when we find tenderness over McBurney's point
in pregnant women, those in the puerperium, or
women suffering from constipation. A pyelitis
on the right side may result from appendicitis by
obstruction of the ureter, exudate, kinking, ad-
hesion, or infection of the stagnant urine.

Other urogenital diseases which may simulate
appendicitis are tuberculosis of the urogenital
system, hematoma in the perirenal tissues, or a
displaced kidney in the cecal region. The latter
may produce pains by distortion of the ureter,
and it may be mistaken for an appendical tumor
or hemorrhagic infarct of the kidney. We know
that hematuria may occur in appendicitis, and,
therefore, we must not lay too much weight on
this finding unless there are renal elements or
albumin in the urine. This hematuria may be
due to toxic causes, functional constriction of
the renal vessels, or retrograde embolus in the
kidney.

A p.
also pt

CHOLECYSTITIS

211

A purulent or hemorrhagic cholecystitis may
also produce symptoms in the ileocecal region,
resembling appendicitis when the gallbladder is
displaced by marked enlargement, long pedicle,
deep position of the liver, or a displacement of
all the abdominal organs due to deformity of the
spine. Here the chief point of importance will
be the fact that the point of tenderness is located
somewhat higher than in appendicitis. There is
evidence of low position of the liver, with ten-
derness corresponding to the displaced incisura.
We will be unable to outline the upper border
of the gallbladder enlargement as we are able
to do in periappendical tumor. The latter tumor
is, as a rule, more or less parallel to Poupart's
ligament, while a large gallbladder is usually
perpendicular to this line. We may also find a
painless tympanitic zone between the dullness
of the gallbladder tumor, and Poupart's ligament
as well as urobilinuria, urobilinogenuria, and
nuckoalbuminuria.

Acute, Continuous Pain in the Ileocecal

Region
Acute continuous pain in the ileocecal region
is more common than genuine colicky pain. It
is of practical value to divide this group into a
part with subjective symptoms only and another
in which we find objective signs on palpation,
as well as symptoms. Our first thought in both

212 ABDOMINAL FAIN

these instances will be appendicitis and periap-
pendicitis.

In female patients, we must consider an affec-
tion of the female genitalia when there is a tu-
mor mass in the ileocecal region, and we must
earefully examine all female patients with this
point in mind. It is especially the parametritis
which may simulate the periappendicitis, but tor-
sion of an ovarian cyst, tumor of the Fallopian
tubes, and extrauterine pregnancy may also re-
semble it. The difficulty may be very great as
the exudate in parametritis may collect rather
high up, while that in periappendicitis may col-
lect in the small pelvis. In addition to a history
of previous abortion or instrumentation or gon-
orrhea, it is important to find an absence of ab-
dominal rigidity and of leucocytosis. There is
a strict localization of the pain to the ileocecal
region in these cases of high parametritis, and
the pain does not begin diffusely with subsequent
localization in the cecal area, but rather radiates
to the hip. The chief point of tenderness in
parametritis is, as a rule, lower than, and a little
internal to McBurney's point. High fever and
a clean tongue point to parametritis. A bilat-
eral tumor usually means parametritis, but we
must not forget that an appendicitis may also
cause an exudate tumor in the region of the sig-
moid. In the latter instance the left-sided tumor
appears after the primary one on the right side;

EXTRAUTERINE PREGNANCY

furthermore, it will show no relation to the
genitalia. Rectal or vaginal examination will
show the periappendical mass situated behind
the uterus, while a parametrial mass is located
laterally or externally to the uterus, pushing this
organ over to the opposite side, while the uterus
itself may he fixed to the wall of the pelvis. Bi-
manual, rectal, or vaginal examination will en-
able us to distinguish a pyosalpinx from a peri-
appendicitis. A stormy course and peritoneal
collapse point to a periappendicitis.

Extrauterine pregnancy with rupture or abor-
tion is manifested by the general signs of preg-
nancy and AbfarhaMen reaction, but chiefly by
the signs of severe intraabdominal hemorrhage
with marked anemia, increased pulse rate with
normal or subnormal temperature, and collapse
in severe cases. Fever may appear later if a
secondary infection appears. A retrouterine
hematocele which has undergone suppuration
will he recognized by gynecological findings.
Menstruation may also cause pain in the right
iliac region, and we must remember that an ap-
pendicitis may light up at this time as a result
of the hyperemia in this region.

In regard to differentiation between torsion
of an ovarian tumor or cyst on the right side and
acute appendicitis, it may be mentioned that in
tumor of the ovary the growth is smooth and in-
creases rapidly in size. Moderate leucocytosis

214 ABDOMINAL PAIN

may be present both in tumor and appendicitis
and cannot, therefore, be used in the differentia-
tion. The usual gynecological criteria must fur-
nish the chief diagnostic features in these cases.
A sign which, according to my experience, may
be of some value, is a difference in the size of
the pupils, in which the right is larger than the
left during an attack of pain arising from intes-
tinal or appendical causes — a sign which I have
not observed in pain of gynecological origin.

Female patients often complain of pain in the
ileocecal region at the time of menstruation. It
must be remembered that various diseases may
become clinically aggravated during menstrua-
tion, and this is especially true of chronic appen-
dicitis. This disease may begin, or the recur-
rences may manifest themselves, only at these
times.

Torsion of the omentum may produce symp-
toms resembling appendicitis. The pain appears
suddenly, is localized in the ileocecal region, or
is diffuse over the abdomen, while fever, vomit-
ing, and constipation are also present. We may
find a palpable tumor or dullness in the ileocecal
region. Gangrene and diffuse peritonitis will
follow if the torsion of the omentum is complete
and if its vessels are blocked. If the torsion is
incomplete, the pains and tenderness will di-
minish, while the tender tumor and moderate
fever persist. The tumor often feels like a super-

ACUTE PERICYSTITIS 215

ficial, tender, finely nodular, well-defined mass
which may rapidly increase in size, even reach-
ing to the size of a head. The fact that the dull-
ness is not so diffuse in the ileocecal region as
in appendicitis, but is more circumscribed by a
tympanitic zone to the right of the dull area, may
be of some use. Leucocytosis is not so marked
as in appendicitis.

Acute pericystitis may also come into ques-
tion in some cases. In cases in which the appen-
dix or the resulting inflammation extends into
the pelvis, we may have strangury, dysuria,
and retention as predominant symptoms. The
finding of a large mass on rectal examination
speaks rather for a periappendicitis, as such a
large mass rarely occurs in pericystitis. In fa-
vor of appendicitis is the absence of previous uri-
nary disturbances. Albumin or pus in the urine
speaks, of course, for cystitis, but a periappendi-
citis may extend to the bladder and secondarily
involve the perivesicular tissues. Perforation of
the appendix into the bladder has been observed,
and the process may either heal or a chronic fis-
tula may result. The rinding of cholesterin in
the urine is, according to my experience, of im-
portance in these cases of perforation. Usu-
ally, however, this process is chronic, extending
over many years, and is mistaken for prosta-
titis, cystitis, etc. We are more likely to be mis-
taken in those cases in which there is pus in the

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7>>t *.ih^r^i/:*ii aoisendicha resembles the sim-
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TUBEBCULOUB ULCER OF CECUM 217

findings. The picture of simple acute periappen-
dicitis is very closely imitated when such a tuber-
culous appendicitis perforates into a previously
walled-off peritoneal pocket, or if the inflamma-
tion extends by continuity to the periappendical
tissues.

Tuberculous ulcer of the cecum without in-
volvement of the appendix may be followed by
a local adhesive peritonitis, usually tuberculous
in nature. Tuberculosis of the cecum produces
early vomiting and diarrhea and later constipa-
tion and also colic. The X-ray may help us to
recognize the condition. Perforation of such a
tuberculous cecal ulcer into this adhesive peri-
tonitis may occur and may produce multilocular
pockets which may contain feces or pus. It is
more rare for the cecum to be secondarily in-
fected from the appendix. We may be able to
palpate a mass in the ileocecal region if there
is no pre-existing peritonitis. The clinical symp-
toms of perforation of such a cecal ulcer wUl
depend on the existence of a previous walling off
of the process. If the process is not walled off,
we find the severe symptoms of a localized peri-
tonitis. If walling off has occurred, the pains
of the perforation may be very moderate or even
absent, and the formation of such a fecal abscess
may be as symptomless as in carcinoma.

Perforation of an ileocecal ulcer with plugging
of the hole may not be followed by the typical

218

ABDOMINAL PAIN

general symptoms of perforative peritonitis, as,
for example, when we are unable to demonstrate
free air in the peritoneal cavity and when the
abdomen is soft and somewhat tender with no
rigidity on light palpation and either meteorism
or a drawn-in abdomen. Tenderness of marked
degree may be obtained on deep pressure ; there
is only transient rigidity and then only during
the time that deep pressure is applied. We may
explain these latter phenomena in patients with
lung tuberculosis by assuming that the muscles
are atonic as a result of loss of strength. There
may be the usual outspoken symptoms of acute
perforation peritonitis over the involved area.

There is another possible relation between
tuberculosis and pain in the ileocecal region. In
addition to the rare cases of diffuse tuberculous
peritonitis which set in acutely there are also
localized tuberculous peritonitis with acute onset.
Such a condition may be secondary to tuber-
culous affection of the intestines or female ad-
nexia, or it may be a primary localized serositis.
In these cases, as in acute periappendicitis, we
see an acute onset with pain, fever, nausea, and
vomiting and a perityphlitic tumor mass de-
velop in a short time. This mass consists of
serotuberculous exudates with adhesions of the
omentum. The course of the disease, absence of
leucocytosis, and marked and constant Diazo re-
action will all be of importance. Signs of tuber-

TUBESCULOUS PEHITONITIS 219

culosis elsewhere, although suggestive, are not
conclusive evidence that the abdominal condition
is also tuberculous.

Comparatively mild pains in the ileocecal
region may be due to an early stage of localized,
dry, tuberculous peritonitis in this region. An-
other condition causing recurring colics in the
ileocecal region is tuberculosis of the mesenteric
or pericecal glands.

Diffuse, tuberculous peritonitis, setting in like
an ordinary acute periappendicitis, will be rec-
ognized by its course. Generally the fever di-
minishes after a few days but does not entirely
disappear. The diffuse tenderness which is es-
pecially marked in the ileocecal region may re-
main constant. The pulse remains wonderfully
good and may be in striking contrast to the fe-
ver. The abdomen is somewhat distended, ascites
develops, and the Diazo reaction is positive.
These are all important findings.

General miliary tuberculosis may cause appen-
dical symptoms as a result of development of
miliary tubercles on the peritoneum in the ileo-
cecal region or by irritation of the intercostal
nerves or diaphragmatic pleura. The diagnosis
will be based on the ashy cyanosis, rapid breath-
ing, absence of auscultatory findings over the
lungs upon which there are areas of tympany,
choroid tubercles, enlargement of the liver and
spleen, and the positive Diazo reaction in the

220

ABDOMINAL PAIN

urine. There may be meteorism, but the abdo-
men can be pressed without causing pain. The
X-ray examination may be of some value in
these cases.

Pneumococcic peritonitis may also localize in
the ileocecal region just as may localized tuber-
culous peritonitis. The pneumococcic exudate
tends to localize in the periumbilical region. As
before mentioned, it is especially common in
young girls, it is often accompanied by diarrhea
and herpes, and we may find the bacteria, Ieuco-
cytosis, and increased fibrin in the blood.

Typhoid may also lead to acute perityphlitis
with or without demonstrable exudate. It may
follow typhoid ulceration of the cecum. The
same clinical picture may occasionally be pres-
ent as a result of marrowy swelling or even sup-
puration of the paracecal glands or typhoid ulcer-
ation of the appendix, which in rare cases may
lead to scar formation with stenosis or kinking
of the appendix and resulting stasis of the con-
tents with subsequent infection. In such cases,
the symptom complex of typhoid fever will be
followed by the characteristic symptom sequence
of appendicitis. The rapid increase in pulse rate
and the local symptoms will be suggestive.

Typhoid ulcer of the ileum, cecum, or appen-
dix may lead to periappendicitis or perityphlitis
in another way, namely, by perforation into a
previously walled-off space or by extension of

the in
cases

TYPHOID FEVEE

221

the inflammation through the serosa. In these
cases there will be the usual typhoid history,
acute tumor of the spleen, diarrhea, leucopenia,
and the bacteriological as well as the serological
findings. Ambulatory typhoid may sometimes
cause a similar picture and lead us to believe that
the periappendicitis occurred in a previously
healthy person. Typhoid is more likely to cause
perityphlitis than appendicitis, by perforation
or extension of a typhoid ulcer.

Typhoid fever as such may produce a genuine
typhoid appendicitis even in the absence of a
perforating ulcer. As a matter of fact, the in-
testinal involvement in typhoid may be strictly
limited to the appendix, or the process may be-
gin with pseudoappendical symptoms which are
probably caused by intense swelling of the
lymphoid tissue in this organ. We must also
remember that typhoid fever may light up a
dormant appendicitis as a result of the local hy-
peremia. A relapse of typhoid may begin with
ileocecal pains even if the first attack did not
show such a picture. The typical local findings
of appendicitis may be found in all these cases.

The following points suggest typhoid fever:
the pulse is slow and dicrotic, a feature which
occurs only rarely in appendicitis, there is marked
initial headache, and the blood may show leuco-
cytosis early, but is soon followed by a leuco-
penia with a relative lymphocytosis, while a rela-

222

ABDOMINAL PAIN

tive polynuclear leukocytosis is always present
in appendicitis, even in the presence of an abso-
lute leucopenia in the very septic cases.

The same that has been said about typhoid ap-
plies to paratyphoid fever. Malta fever and ma-
laria may also cause similar symptoms.

Lobar pneumonia may cause pain in the right
iliac region, especially in young people. This
is most common in involvement of the right
lower lobe with radiation of the pleural, dia-
phragmatic, or perihepatic pains by irritation of
the intercostal nerves or of the diaphragmatic
pleura, by secondary pneumococcic peritonitis
either localized at the cecal region or diffuse, or
by lighting up of a. dormant appendicitis. Lo-
bar pneumonia in these cases is recognized by
the flushed face, initial chill, headache, lagging
of one side of the thorax on respiration, bulging
of the ileocecal region during this act, absence
or diminution of Litten'g sign, cough, herpes,
blood findings, and strikingly high rate of res-
piration as compared with the pulse rate, so that
normal proportion of one to four is reduced to
one to three or even less. The rigidity of the
abdominal muscles may be caused by irritation
of the parietal peritoneum and transmitted from
the pleura via the intercostal nerves. This
rigidity is, as a rule, more diffuse than in appen-
dicitis. If we find such a rigidity and, in addi-
tion, a localized area especially marked over the

ACTINOMYCOSIS 223

ileocecal region together with vomiting, singul-
tus, and fever, we must suspect a localized peri-
toneal involvement which may or may not be fol-
lowed by pneumococcic periappendicitis. In
simple peritoneal irritation or peritonism, we ob-
tain marked tenderness on superficial pressure,
but if we palpate slowly and more deeply, the
tenderness is not so intense. The tenderness in-
creases with the pressure in true peritonitis.

We must not forget the possibility of an ac-
tinomycosis when we ore dealing with an appen-
dicitis or perityphlitis if there is an exudate
mass. The diagnosis will be possible only un-
der favorable conditions. There is very little or
no fever in spite of the presence of a mass, the
pains and vomiting are moderate and often re-
cur, and the tumor is adherent to the skin, which
may be edematous, thick, and of a strikingly
grayish violet color over this area. We must
look for a possible portal of entry, examine the
serum and pus from a fistula, perform the spe-
cific agglutination test, and look for the organism
in the feces. Chronic actinomycosis of the cecum
may also become secondarily infected and may
produce acute attacks very much resembling
acute appendicitis. On the other hand, the ab-
sence of an acute onset should remind us of the
possibility of an actinomycosis or tuberculosis of
this region. Carcinoma and lymphosarcoma of
the cecum and carcinoma of the appendix, as well

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Pleurisy i^'i Iii?cr*gnitfcLC pleurisy mar also
simulate ar ren-iicrds in the suae wav in which
the pleural inTc-IvennKit in pneumonia causes this
phenomenon. Here, again, we find only super-
ficial tenderness in the ileocecal region, with no
marked rigidity. The differential diagnosis may
be difficult in empyema where we also find a
high pulse rate, leucocytosis, and severe sepsis.

Purpura abdominalis will be recognized by the
hemorrhages into the skin and mucous mem-

GASTROINTESTINAL INFLUENZA 225

branes, occult or manifest malena, pains or
swelling of the joints, vomiting, constipation, and
increased temperature during the attack. Ten-
derness is found rather over the entire cecum than
over McBurney's point alone. There is also
eosinophilia and increase in the number of blood
platelets.

Hemorrhagic diathesis must remind us of the
possibility of a leueemia, a condition in which
moderate ileocecal pains may occur. We must
carefully examine the condition of the gums,
spleen, glands and blood. This disease may be
easily overlooked, especially when there are pains
in the throat and fever.

Acute epidemic cerebrospinal fever may be ac-
companied by pains in the ileocecal region with
local rigidity and vomiting. These symptoms are
caused by inflammatory irritation of the spinal
roots.

The gastrointestinal type of influenza is char-
acterized by severe prostration, pains in the mus-
cles and limbs, initial headache, tenderness of the
sinuses, frequent diarrhea, symptoms of catarrhal
involvement of the respiratory tract, and the
usual bacteriological findings. As a. rule there is
diffuse tenderness in the ileocecal region rather
than a distinctly localized painful area. In the
last epidemic of influenza we sometimes found a
mass in the ileocecal region which was an hemor-
rhagic colitis, appendicitis, or lymphadenitis.

226

ABDOMINAL PAIN

Scarlatina may cause pain in the ileocecal
region in children, with vomiting, probably as a
result of the inflammation of the lymphoid tissue
in the appendix. The same is probably true in
cases of acute infectious angina with ileocecal
pains. Such attacks have been observed in five-
day fever with diminution of the pains during the
intermittent intervals.

Osteomyelitis of the right femur, pelvic bones,
and sacral and lumbar spines must also be men-
tioned. Pseudoappendicitic symptoms, such as
abdominal pain in the right lower quadrant, acute
onset, fever, vomiting, diarrhea, and flexion of
the hip joint may occur when the focus is near
the knee as well as when it is near the hip. Pain
will be elicited by moving the thigh in any direc-
tion, and there is muscular fixation of the hip, no
rigidity in the cecal region, or tenderness over
the appendix, but there is marked tenderness and
swelling of the thigh. X-ray may help us to
clear up the diagnosis. Osteomyelitis of the right
iliac bones near the crest or near the right sacro-
iliac joint or symphysis may produce similar
symptoms. The X-ray and localization of the
symptoms and of the tenderness will clear up the
diagnosis.

We occasionally find patients with syphilis in
the secondary stage who complain of intense ileo-
cecal pains and fever.

Dysentery extending high up may cause pain

INTESTINAL PARASITES

in this region as a result of spasm of the colon,
but the usual history and examination, especially
of the stools, together with the serological find-
ings, will help us in the diagnosis.

Intestinal anthrax may produce a tumor mass
over the appendix region, but this is not a con-
stant finding. There are chills, fever, moderate
pains, and marked tenderness in the ileocecal
region. Ascites, either serous or hemorrhagic, is
found in the early stages. The tumor may be pal-
pable on rectal examination. This tumor may
consist of carbuncles of the cecal mucosa or of
hemorrhagic edema of the submucosa.

Children may have intestinal parasites in the
cecum, and these may produce pseudoappen-
dical symptoms, even if the worms do not enter
the appendix. Intense pains in the cecal region
may appear, as may signs of peritoneal irritation
such as nausea, vomiting, diarrhea, fever, and
even a tumor-like mass. This is most common
in ascaris but has also been seen in trichocephalus
dispar. It will be important to examine the stools
of these cases for eggs or parasites and the blood
for eosinophilia. The stools in ascaris show a
markedly disagreeable, aromatic odor. Eosino-
philes may be also found.

Purulent periureteritis must also be mentioned.
It may be an extension by contiguity from the
ureter, or perforation, as by a stone. In both in-
stances there is sudden, intense pain, vomiting,

228 ABDOMINAL PAIN

fever or subnormal temperature, bowel disturb-
ances, perhaps complete stoppage of feces and
flatus, and a very tender, quickly developing tu-
mor in the ileocecal region. The diagnosis may
have to be based only on the history in these cases,
as all examination, even X-ray, may be danger-
ous or even impossible.

The simple acute ascending inflammation of
the ureters, as from primary affection of the pros-
tate, bladder or female genitalia, will be charac-
terized by pains, vomiting, fever, and the pres-
ence of a tender, tubular mass, which is dull on
percussion and which corresponds to the ureter.
The localization of this mass in the usual location
of the ureter, on the inside of the small pelvis,
as well as the tender points along the location of
the ureters, will be suggestive of an affection of
this part. We find similar signs in acute hydro-
ureter such as is seen in pregnant women. Such
cases may also show pains which radiate to the
loins, with tenesmus and diminution in the out-
put of urine.

Gonorrhea of the vas may also resemble the
picture of appendicitis by causing fever, pain,
and local tenderness. I have also seen a case of
inflammation of the vas with bilateral pains in
the iliac regions after typhoid which later healed
without any traces of the affection.

Acute psoas abscess may simulate appendicitis,
especially when there is a perityphlitis result-

PSOAS ABSCESS 229

ing from the abscess. We find the same posture
of the patient with his flexed thigh and knee, and
there is no vomiting and no typical tender point
or hyperesthesia of the abdomen. Simple appen-
dicitis does not force the patient to keep his thigh
flexed all the time, while psoas abscess, retro-
cecal inflammation, or retrofascial inflammation
causes the patient to maintain this attitude con-
stantly. There are no signs referable to the in-
testines proper. The psoas abscess may be bi-
lateral but is differentiated from an extension of
the appendicitis to the left side by the fact that
the former develops simultaneously on both sides,
while in appendicitis the process is first seen on
the right and then on the left side. Bilateral
psoas disease will cause a bilateral fixation of the
hips, while we do not find fixation of the left hip
in perisigmoiditis. It is impossible to over-extend
the hip joint in the former condition when the
patient is in the prone position. This sign is of
especial value in cases of psoas affection develop-
ing acutely, as after trauma. We must try to
find the primary focus as in the ribs or spine.

In cases of chronic psoas abscess, the pains are
not so marked as in appendicitis, and may even
be entirely absent. The tumor is much flatter,
and the pains have a tendency to radiate to the
thighs and genitals, a radiation which occurs only
in the retrocecal type of appendicitis and which
may be followed by an involvement of the psoas

230

ABDOMINAL PAIN

muscle. X-ray will be of value, in that it will
show displacement of the cecum and that the first
part of the ascending colon is pushed to the left
in psoas abscess. A marked leucocytosis and the
before-mentioned pupillary difference will point
to appendicitis unless there is considerable lung
involvement.

Purulent or tuberculous disease of the hip joint
will cause similar symptoms either by perforation
of the pus through the bony fossa into the large
pelvis and then into the psoas, or as a secondary
suppuration of the lymph glands in the ileocecal
region. In addition to the X-ray findings, the
limitation of the hip joint in all directions is of
importance. Vomiting and suppuration may oc-
cur in the before-mentioned suppuration of the
glands. If a tuberculous hip joint is followed by
a localized and later diffuse tuberculous perito-
nitis, the sequence of symptoms will be of impor-
tance. There are symptoms referable to the
joint, later, signs in the ileocecal region, and still
later, signs of a diffuse peritonitis. When the
heel is suddenly pushed while the entire lower
extremity is in full extension and somewhat
raised, the patient will complain of pain in the
hip joint. If the sign is to be of value, however,
the patient must localize the pain with certainty
in the hip joint. An uncircumscribed pain in this
region when this test is performed may be due to
acute appendicitis and peritonitis hut is not pres-

UNDESCENDED TESTICLE

ent in appendicitis which is walled off. I wish to
point out that an appendicitis may produce a
metastatic coxitis which in turn may cause a
slight degree of lameness, neuritis of the crural
nerve, or reflex involvement of the psoas muscle.

An undescended testicle may come in question
if we find only one testicle in the scrotum. Acute
inflammation of such a testicle or of the descended
organ may simulate appendicitis, especially when
caused by trauma or local or general infection.
For instance, in epidemic parotitis such inflam-
mation of the testicle may occur as the only symp-
tom of this disease and may be followed by pains,
fever, and vomiting. The same may occur in
females with oophoritis on the right side. In
cases of torsion of an intraabdominal testicle,
there may also be ileus and collapse ; or the pass-
ing of a testicle through the inguinal canal may
cause faintness, intense pain in the ileocecal
region, vomiting, and constipation. Sarcoma of
such a testicle may produce fever and a rapidly
growing tumor.

Intussusception in the ileocecal region will be
characterized by the absence of signs of inflam-
mation in the early stages of the disease, mod-
erate or even no tenderness of the palpable tu-
mor, and no typical tender points or hyperesthesia
of the skin, but there will be a distinct peristalsis
near the tumor mass.

Other conditions are volvulus of the cecum and

232 ABDOMINAL PAIN

purpura abdominalis of the lower loops of the
ileum, as well as compression of the cecum by a
wandering organ, as a spleen or kidney.

Carcinoma of the cecum may run a mild course
and suddenly light up with a stormy clinical pic-
ture. In all cases of tumor in the ileocecal region
we must exclude the possibility of a fecal mass,
as the nodular surface and hardness may lead us
to believe that we are dealing with a malignant
tumor. Such a fecal mass may remain even after
an effective enema or after several bowel move-
ments.

Acute phlebitis of the right iliac vein may
show intense and sudden pain in the ileocecal
region, and local tenderness and rigidity; but I
have also seen cases with no vomiting or other
intestinal disturbances. The presence of gen-
eral sepsis, inflammation, or neoplasm in the
lower extremity, small pelvis, or the vicinity of
the iliac vein is of importance. Cases of embolus
or thrombosis of the superior mesenteric artery
or vein, especially of the ileocolic vessels, may be-
gin with stormy and diffuse symptoms or with
localized pains in the ileocecal region.

Affections of the lymphatic glands in the vi-
cinity of the ileocecal region may cause pseudo-
appendical symptoms. It is especially the peri-
cecal glands which may enlarge and become pain-
ful without any involvement of the appendix
itself. The diagnosis may be made on palpation

LYMPHATIC GLANDS 233

of these glands. Such affections of the glands
may result from plague or other acute infectious
diseases, as well as from tuberculosis, acute gran-
uloma of Sternberg, leucemia, and neoplasms.
Inflammatory infections of the lower extremity
may involve the glands in this region without af-
fecting the inguinal glands. Inflammation, in-
fection, or hemorrhage into the mesenteric glands,
as in typhoid, may also cause such symptoms.
Free bleeding in this region, as from hemorrhagic
diathesis or erosion of a vessel, as by carcinoma,
may also cause this picture. Retroperitoneal
hematoma of traumatic origin or a perirenal
hematoma which has gravitated downwards may
cause such pains. Signs of acute internal hemor-
rhage will be of importance in all of these cases.

Another cause for pseudoappendical pain is
tumor in the retrocecal region, either benign or
malignant. The pain may be caused by the tu-
mor itself or by the results of necrosis. Acute
appendicitis may even be caused by an extension
of the infection from the tumor mass.

Very sudden and intense pains with shock
should always remind us of the possibility of a
rupture of the intestine, a condition which occurs
most frequently at the cecum because this is the
favorite place for ulceration of various types and
also the thinnest part of the colon. The cecal
contents are likely to disintegrate with gas for-
mation, and this collection of gas will be kept in

234 ABDOMINAL PAIN

situ by the ileocecal valve, while the thinness of
the wall allows a maximal distention at this place.
This condition may produce intense pains in the
cecal region, as the pains are greatest in the place
of greatest distention rather than in the place
of obstruction. Vomiting will appear rather late
and practically never on the first day as in ap-
pendicitis. The enlarged colon may be palpable,
and there may be tenderness over the obstruction
as well as over the region of greatest distention.
There is usually no leucocytosis and no abnormal
difference in the rectal and axillary temperatures
will be noticeable.

We will find the usual signs of intestinal
obstruction in these cases. This picture occurs in
organic stenosis, in marked ptosis of the trans-
verse colon, with kinking of the bowel, or after
an enema, especially in a cecum which has for-
merly been diseased. It will be of importance
in cases of cecal collections of gas to find bulging
in the flank while there is no meteorism in the
region of the navel. Perforation of the cecum in
such a case will produce free air in the peritoneal
cavity.

Perforation of the stomach or any part of the
small intestine from any cause may produce a
picture in which the subjective and objective
findings are most marked in the ileocecal region
or at McBurney'a point. This may be explained
by the fact that the exudate gravitates to this

PERFOHATION OF STOMACH 23o

region and is more superficial here than in its
former location. If we obtain tenderness over
the epigastrium with radiating tenderness over
the appendix by pressing over the former loca-
tion, we may be dealing with an appendicitis,
but if there is no such radiation, then it is very
likely that there is no true primary appendical
involvement. The difficulty will be very great
in those cases of perforation in which there is no
epigastric tenderness at all. If we can examine
the patient within twenty-four hours after the
rupture, we may find rigidity only of the upper
rectus muscle and none in the ileocecal region.
The abdomen may be drawn in as the course pro-
gresses. Very important is the type of radiation
of the pain. In perforation of the stomach, the
pain radiates to the left of the spine, left shoulder,
or between the shoulder-blades. In duodenal
ulcer the radiation is to the right of the spine,
at the level of the duodenum. The absence of
fever or even the appearance of a subnormal tem-
perature immediately after the onset of the pain
points rather to perforation of an ulcer than
to appendicitis. The previous history will also
be of some value. Costal respiration is not char-
acteristic of rupture of the upper part of the
gastrointestinal tract, as it may also occur in per-
foration of the lower portions.

Displacement of the pylorus, as in marked
ptosis or dilation, may, in the presence of disease

233 ABDOMINAL PAIN

of this part, simulate appendicitis when the py-
lorus lies near the region of the appendix.

Other diseases which may occasionally resemble
appendicitis are pancreatitis, diaphragmatic her-
nia, or pancreatic necrosis. The entire abdomen,
or at least the greater part of it, will be tender,
while rigidity is often absent. Fat necrosis near
the appendix in cases of pancreatic disease may
be the cause of such pains. A mass composed of
adherent intestines may even be felt.

For the differential diagnosis between appen-
dicitis and gallbladder disease see the chapter
dealing with liver colic and gallbladder disease.
In this connection it may be mentioned that a fre-
quent cause of radiation of pain from the gall-
bladder region to the appendix may be brought
about by a nephroptosis of the right kidney.

Acute intestinal urticaria may cause similar
symptoms, but we also find either an urticaria of
the skin at the same time or eosinophilia in the
blood or feces at a later period, and the condition
may improve under calcium treatment.

Pseudoappendicitis may occur as a form of
hysteria or neurasthenia, especially of a visceral
type, usually in the presence of some slight intes-
tinal trouble. There is no alteration of the pulse
or temperature, there are no local objective signs,
and the tenderness in the appendical region is only
superficial, and as shown by the fact that raising
of a fold of skin causes pain, while deep pressure

HYSTERICAL FEVEB 287

which is slowly increased is less painful. Dysuria
may be present in these cases. The course of the
affection will show the true nature of the disease.

It must be mentioned that there may be a so-
called high hysterical fever with a palpable tumor
mass formed by the contracted cecum. We must
remember that there is a point of tenderness
over the ovaries, or even somewhat higher, as at
the level of McBurney's point, in hysteria, and
we must not mistake this point for one of appen-
dical origin. In regard to the stigmata of hys-
teria it must be said that the presence of these
does not prove that the pains in question are of
hysterical nature. This conclusion is best reached
by noting that there is a disproportion between
the severity of the symptoms and the physical
signs.

Patients suffering from appendicitis may ex-
perience pains after eating because they fear to
take sufficient nourishment, and as a result they
lose weight and strength. A secondary neuras-
thenia may develop as a result of this. These
patients will complain of pain in the same region
in contradistinction to pains of functional origin
which have a tendency to shift in location.

Quincke's angioneurotic edema may also cause
transitory pains in the ileocecal region. The pres-
ence of periodic edema of the skin and mucous
membranes, intermittent swelling of the joints,
gastric disturbances, and pseudoasthmatic attacks

238 ABDOMINAL PAIN

or attacks of migraine, and possibly the family
occurrence, will be of value.

Bleeding in the covering layers of the spinal
cord of the lower thoracic portion, acute purulent
peripachymeningitis, and fracture of the trans-
verse process by caries of the spine in which the
segments are brought closer together and in frac-
ture of the lower ribs, all these may be followed
by pains in the ileocecal region due to irritation
of the posterior spinal roots. Herpes zoster will
occur in cases of fracture of the ribs as well as
reflex rigidity of the abdominal muscles, sensory
disturbances, and other disturbances resulting
from affection of the spinal column.

Simple neuralgia of the intercostal or upper
abdominal nerves, as in influenza or malaria, may
cause difficulties. Similar pains may be caused
by irritation of the nerves by a retroperitoneal
or kidney tumor. The presence of paravertebral
points of tenderness, the superficial location of
the pain, and the course and radiation and diminu-
tion of the reflexes on the affected side will be
of importance. There are rare cases of sciatica
which begin with pain in the ileocecal region and
which may even show tenderness at McBumey'g
point. There will be pain and tenderness along
the crural and sciatic nerves in addition to the
other symptoms. We must not forget that a
sciatica may be purely symptomatic in a genuine
appendicitis.

POLIO JI YELITIS — TETAN Y

Tabes dorsales may cause pain in the ileocecal
region, either as an abdominal crisis or by girdle
pains in the region of the right iliohypogastric
or ilioinguinal nerves.

Caries of the spine may cause such pains either
on a nervous basis or as a result of a psoas ab-
scess in the ileocecal region.

Early stages of acute anterior poliomyelitis
may imitate appendicitis by causing initial vom-
iting, gastroenteritic symptoms and fever, es-
pecially if hyperesthesia of the skin and intense
muscle pains are localized in the lower right abdo-
men. Similar areas of hyperesthesia and tender-
ness elsewhere, the absence of one or more tendon
reflexes, leucopenia, sweats, and muscle pareses
will aid in the diagnosis.

Tetany may occasionally set in with intense
cramps in the abdomen, and the spasm of the
colon may be so marked that it closely resembles
the clinical picture of intestinal obstruction. The
pains in this condition may be due either to the
cramps or to the causative pyloric stenosis or
other factor of the original tetany.

Graves' disease may occasionally cause pains
in the ileocecal region as a result of the diarrhea
and may persist for several days. The moderate
pains in the abdomen may be due to some affec-
tion of the lymphoid structures in the small intes-
tines, as in a "cold," etc., which involves the
tracheal glands and extends to the other lymphoid

240

AltDOMISAL PAIN

structures. In cases of general lymphoid hyper-
plasia, symptoms of appendicitis may occur as
a result of this hyperplasia without any actual
inflammation of the appendix itself.

Inflammation of the skin and muscle of the
abdominal wall over the appendix may resemble
appendicitis but is recognized by the superficial
tenderness, doughy swelling in the skin, and ab-
scess in the muscle. Real myalgia, due to rheuma-
tism or overwork, must also be considered, as
there may be tenderness on the external border
of the rectus near McBurncy's point, since the
nerves enter their sheaths at this place. This
tenderness will be bilateral, and is more marked
on raising up the head, while in appendicitis there
is less tenderness upon contraction of the rectus.
The tender point will shift with the particular
point in the abdominal wall as the patient
changes position. The place of intersection of
the muscles may also be tender. A history of
over-exertion, as cough, strain, etc., will also be
of value. A tear in the abdominal muscles will
be recognized by the local swelling and tender-
ness.

Recurrent Pains in the Ileocecal Region
If a patient complains of recurrent pain in this
region, with the typical symptoms of appendi-
citis and after proved previous attacks of appen-

CHBONIC CHANGES IN APPENDIX 241

dicitis, we will of course consider the present at-
tack as arising from the appendix.

The most common causes are chronic changes
in the appendix or its peritoneal vicinity, if the
appendix has not been removed. We find mod-
erate, dull pains after meals, while the patient is
walking upstairs, while he is stooping over, or
during movement of the bowels. There are local
tenderness and gurgling, and sometimes a strand-
like mass may be palpable. The attacks may be
very intense, with vomiting and fever. Adhesions
may indirectly cause attacks by forming diverti-
cula? in the cecum, in which places stasis of fecal
material may occur. Spasm of the colon, due to
nervous disturbances or adhesions, may also cause
such attacks. The occurrence of appendicular
colic is another frequent cause.

Inflammation and suppuration may also ex-
tend to the omentum, causing omentitis. In these
cases the tumor appears to be located immediately
behind the abdominal walls and is flat and quite
large. The omentum may be fixed in the ileocecal
region after removal of the appendix, and when
it becomes painful it may resemble a genuine
appendical attack.

Other conditions which may cause attacks of
pain after previous attacks of appendicitis are
abscess of the abdominal wall and constipation
colic. The pain in colic will be of the true intes-
tinal type of colic, with attacks of a few minutes'

242

ABDOMINAL PAIN

duration in wave-like rise and fall of intensity,
and with a tendency to wander from right to left.
These pains need not always begin in the ileocecal
region. Local pressure lessens the pain; there
may be scybala in the rectum or sigmoid, and an
enema brings relief. What has been said of con-
stipation colic is true in simple colic after a dietetic
or "cold."

If a typhlocolitis was the cause of an appendi-
citis, it may still be the cause for future attacks
of pain after the appendicitis has subsided. Ptosis
of the colon and mucous colitis must also be con-
sidered.

Adhesions may be located in the transverse
and ascending colon and may lead to intermittent
attacks of flatulence with painful distention of
the cecum or incarceration by strands of adhe-
sions. The X-ray will be of value in these cases.
The ureter may be involved by the inflammation,
and connective tissue may form about it, causing
a stenosis with resulting colics. Such a stenosis
may be followed by a pyelitis or even formation
of stones in the pelvis of the kidney.

Postoperative hernia in or through the abdom-
inal wall may be the cause of repeated attacks of
pain in the appendix region after removal of this
organ. Varices of stumps of the ligated veins
after operation may produce a tumor mass in this
region.

Finally, we must remember that a dormant

PAINS IN CECUM 243

infectious process or focus may remain after a
gangrene of the appendix and may light up sev-
eral months after operation.

Clironic, recurrent pains in the cecum may be
due to cecum mobile, or atony of the cecum, both
conditions being a part of a general atony or en-
teroptosis. The attack itself may be caused by
a torsion of the abnormally movable cecum, pos-
sibly by transient spastic contractions in this
region, or occasionally by a secondary typhlitis
which may be ulcerative in nature. The pains
may recur at intervals of hours, days, or weeks
and may resemble those in ordinary neuralgia.

We find, as a rule, little or no fever during
these attacks ; the pains at times show a relation
to the quantity or guality of food, and it may de-
pend on the tonus of the abdominal wall. The
pains are increased when the patient is walking,
or when he assumes certain positions. These
pains are diminished and sometimes disappear if
the patient assumes the right-sided position. The
pains are in the ileocecal region and especially
along the external border of the cecum and
ascending colon and may radiate to the gall-
bladder or right kidney or even be diffuse over
the entire abdomen. The colic may remain for
one or two hours and disappear on the passage
of ill-smelling gas or feces which may even con-
tain pus or blood. The patient may experience
a sensation of gurgling or bulging in the cecal

244 ABDOMINAL PAIN

region. McBurney's point may be tender but is
not the point of maximum tenderness. As al-
ready stated, the maximum point of tenderness
is along the external border of the cecum and
ascending colon. The abdominal rigidity is
usually only slight. We are often able to palpate
the cecum as a movable, tense, elastic, cushion-like
mass, about the size of a small apple, which may
show periodic change in all its features, and which
may show a gurgling or splashing on deep pal-
pation.

These are signs of dilatation of the cecum.
We may sometimes palpate the last part of
the ileum as a thin strand leading to the cecum.
X-ray may show a bismuth residue in the cecum
even after twenty-four to seventy-two hours. The
patients are not entirely well in the intervals
between the attacks; they usually complain of
constipation, irregularity of bowel movements,
and a feeling of local distress. The gurgling
and splashing and signs of a dilated cecum may
also occur in chronic appendicitis, and they are
therefore not pathognomonic of either condition.

Among the other anomalies are very low po-
sition of the ascending and transverse colon or of
the latter alone, which may lead to chrome con-
stipation. This constipation may cause either
pseudoappendical symptoms or even a real ap-
pendicitis.

Other conditions are lead colic, arteriosclerosis

MESENTERIC VESSEI^ 245

of the superior mesenteric vessels, recurring
spasms of the colon, and simple ulcer of the large
intestine. The latter is analogous to the gastric
ulcer and is probably caused by local disturbances
in the circulation. The diagnosis of this disease
is very difficult. We find it in those places where
the intestinal contents are apt to tarry, as in the
cecum or sigmoid flexure though not so commonly
in the splenic or hepatic flexures. When local-
ized in the cecum we find cramp-like pains which
are intense and recurrent and which are relieved
by passage of stools or flatus. We find local ten-
derness and occult or manifest bleeding, but noth-
ing of striking appearance in the stool. Most of
the cases which have perforated have been mis-
taken for appendicitis.

Stenosis of the cecum or ascending colon may
be due to carcinoma, scars, or tuberculosis with
stenosis of the lumen. We find chronic, recur-
rent, colicky pains in the ileocecal region in these
cases, with constipation or constipation alter-
nating with diarrhea. Vomiting may also occur.
If there is a palpable tumor with stiffening we
may easily make a diagnosis, but even if these
signs are absent we may suspect the condition
when we find colicky attacks lasting a few min-
utes or seconds with wave-like increase in severity,
sensation or stiffening or bulging and a feeling
of stagnation in the ileocecal region, and some-
times the patients feel as if there were something

246

ABDOMINAL PAIN

gurgling or squirting at the end of an attack.
There may be occult blood in the stool, and there
may also be large numbers of spirilla; or spiro-
chetes in the feces. The change in intestinal
flora, spirochetes, and X-ray findings will enable
us to distinguish this condition from stenosis due
to tuberculous peritonitis.

Senile patients do not often hare a stormy
onset in appendicitis while adhesions or even
emaciation may develop and simulate malignant
disease. Lymphosarcoma does not usually cause
direct stenosis of the intestine at the cecum, but
narrowing may occur from kinking or pulling on
this part by the extraneous part of the tumor.
The contrast between the strikingly large size
of the tumor and the absence of stenosis will be
suggestive of this condition.

Chronic ileocecal invagination will imitate a
chronic periappendicitis of recurrent type with
a palpable tumor. The patient complains of
recurring colicky pains lasting twelve to twenty-
four hours, which reappear after a few days with
nausea and vomiting. Typical tender points and
rigidity of the muscle will be absent, while stif-
fening and visible peristalsis may be present.
Profuse malena occasionally occurs. The chief
feature is the intermittent contraction of the tu-
mor on palpation.

Large foreign bodies or maggots may also pro-
duce such symptoms of appendicitis. Other con-

ACETONEMIC VOMITING 217

ditions are large hernias on the right side or
patent rings, adhesions of the small intestines,
adhesions about the ascending or transverse colon,
especially at the splenic flexure, or malignant
growths high up in the colon, as at the cecum,
followed by distention colics of the cecum.

A large sigmoid as in Hirschsprung's disease
may also cause similar symptoms and is sometimes
accompanied by membranous colitis.

Acetonemic vomiting in children may also pro-
duce pain in the ileocecal region, but there will
be copious vomiting, acetone odor of the breath,
acetone bodies in the urine, and slow breathing.
There are cases of duodenal ulcer in which the
pain radiates to McBurney's point. Early or
dormant pulmonary tuberculosis may cause either
epigastralgia or pain in the ileocecal region with
tenderness over McBurney's point.

Chronic Continuous Pain in the Ileocecal
Region

Such chronic complaints may vary from a sen-
sation of fullness in this region to severe pains.
We must mention the conditions discussed in the
previous chapter and especially chronic appen-
dicitis and periappendicitis. The chronic com-
plaints in appendical disease may be due to
chronic inflammation of that organ, even puru-
lent or empyemic in nature, or to local peritoneal
adhesions, especially with the omentum, which

248

ABDOMINAL PAIN

may also enclose pockets of pus. Other possi-
bilities are distortions, kinking, and hydrops of
the appendix. These cases may be but a local
exacerbation or general septic spread by the por-
tal vein.

Adhesions about the appendix may cause con-
stant complaints of temporary colicky attacks,
constipation or constipation alternating with diar-
rhea, anorexia, nausea, flatulence, and fever,
especially before menstruation but no palpable
tumor. Hernia may also cause a similar, chronic,
continuous pain, as will also carcinoma of the
appendix or cecum, in which latter a tumor is
not necessarily palpable. There are gradually
developing symptoms of chronic appendicitis
without any previous acute attacks. In addition
there are marasmus and anorexia. The patients
are usually well along in years. There may also
be occult malena. In patients between forty and
fifty years of age who have always had normal
bowel movements but suddenly begin to com-
plain, without any special reason, of irregular
bowel movements, flatulence, or colicky pains, we
must suspect malignancy of the colon or cecum.

Tuberculous ulceration of the intestines causes
similar pains of moderate intensity, local tender-
ness, and meteorism, but no abdominal rigidity.
There is constant gurgling in the ileocecal region,
malena, spirochetes, or even tuberculosis bacilli
in the feces. Early stages of tuberculosis of the

TUBERCULOUS LYMPHOMA

cecum will give a similar picture before the hyper-
trophic tumor develops.

Tuberculous lymphoma may cause chrome
symptoms and is characterized by emaciation,
hectic fever, m'ght sweats, tuberculous glands
elsewhere, and positive tuberculin reaction. The
positive diagnosis of this condition can be made
only by positive exclusion of the previously men-
tioned tuberculous diseases about the ileocecal
region. The same symptoms may be caused by
lymphoma in this region from any other cause,
as retroperitoneal cysts, solid retrocecal tumors,
or chronic psoas abscess. Flexion at the hip
occurs in glandular enlargement around the ce-
cum, appendix, or psoas muscle.

Tuberculosis or actinomycosis of the appen-
dical or periappendical tissues must also be men-
tioned. Simple flatulence may produce this type
of pain in an inflated cecum over which marked
tympany may be obtained. Chronic constipation
of the ascending type may also be a factor, as
may dilatation of the cecum due to obstruction
lower down. Finally, I wish to state that such
pains may be a result of disease of any organ or
tissue in the vicinity of the cecum, as well as of
spinal disease or affection of the abdominal walls.

Acute Pains in the Left Iliac Region

Pains in the left iliac region are much less
frequent than pains in the right iliac region.
They may be acute or chronic or may be an ex-
acerbation in the course of a chronic disease. It
is evident that organs or tissues which are located
bilaterally may cause pain in either side, as, for
example, the female genitalia, bones, joints,
nerves, veins, or abdominal walls.

Our first thought in sudden, intense, colicky
pains in the left iliac region is intestinal colic and
rather an obstruction colic in the sigmoid than a
simple intestinal colic The most common cause
for this obstruction colic is volvulus ; incarceration
is more rare. Such an acute onset may also be
the first sign of a previously existing dormant
stenosis. Local circumscribed tenderness over
the sigmoid is of great importance in these
cases, as the pain may be rather diffuse over
the abdomen.

Such a pain, on the left side, even when accom-
panied by vomiting and symptoms of strangula-
tion ileus, may be caused by nephrolithiasis on
the same side. It will be especially difficult to
diagnose the first attack of this condition when
there is no previous history. I wish to point out

PERIURETERITIS

that pain in the left iliac region accompanied by
pain in the left lumbar region which radiates to
the testicle, penis, or labia is, of course, suggestive
of renal or ureteral disease, but is not a patho-
gnomonic sign for disease in these regions, as such
diseases of the sigmoid as carcinoma or sigmoiditis
may cause a similar radiation. Of greater im-
portance is the fact that in renal disease the ten-
derness is more marked in the lumbar region than
in the left iliac zone and is accompanied by hyper-
esthesia of the skin of the flank. Stone in the
ureter will not cause this sign but will show ten-
derness along the ureter, namely, at a point of
intersection of a horizontal line at the level of
the navel and a perpendicular line at the external
border of the rectus. Real tenderness of the tes-
ticle is important in renal or ureteral disease, as
it does not occur in intestinal conditions. The
same may be said to apply to red blood cells and
albumin in the urine. Ureteral characterization
and X-ray will offer further aid in the diagnosis.

Periureteritis from ureteral stone may cause
a necrosis of the walls and show intense pains,
tenderness, mass in the left lower abdomen, fever,
vomiting, even diarrhea, fixation of the left hip,
and even resulting acute, fatal peritonitis. The
presence of pus cells and albumin in the urine
may be of some value in the diagnosis.

Another possible cause is phlebitis of the left
iliac vein, which is followed by edema of the left

252 ABDOMINAL PAIN

lower extremity, increased temperature, tender-
ness on palpation of the left crural vein, and
even by a mass in the left iliac fossa. The causes
of such a phlebitis are inflammatory conditions of
the left lower limb, hemorrhoidal nodes, diseased
tissue in the small pelvis or lower portion of the
large intestines, and general infections as in ty-
phoid or sepsis.

Parametritis may cause similar pains in the
iliac regions with perhaps palpable mass to the
left of the symphysis in the sigmoid region if the
exudate extends upward. It is important to know
that parasigmoiditis may result from a para-
metritis during the puerperium and is perhaps
caused by constipation. The shape of a para-
metritic mass is like a wing with the tip pointing
outwards, while the wing-shaped mass in perisig-
moiditis does not have its tip pointing in this
direction. Parametritis produces sacral pains
and dysuria, while peritonitic symptoms like vom-
iting are often absent. The other gynecological
findings and the fact that the mass may be bilat-
eral will be of decisive value.

If the pain is not colicky but rather continuous
with exacerbations and remissions and rather dull
in character, we must think of sigmoiditis, either
acute catarrhal, ulcerative, or phlegmonous in
nature. The local tenderness, examination of the
feces, sigmoidoscopy, and agglutination of the
serum in dysentery will clear up the diagnosis.

PEKIBIUM0IMT1S

When the pain is more intense we should think
rather of perisigmoiditis, a condition less rare
than is usually considered. Such a perisigmoi-
ditis may he caused by a great variety of factors,
as, for instance, marked constipation in pregnan-
cy, ulceration of the sigmoid as in dysentery, car-
cinoma, diverticula? of the sigmoid, foreign bodies,
and metastatic spread from other places which
are acutely affected, as, for instance, from a se-
vere infectious bronchitis or extension from the
appendix or female genitalia. The clinical pic-
ture of a perisigmoiditis consists of pains in the
left iliac region which are intense, continuous, and
occasionally radiating to the left lower extremity.
There are epigastric pains in the early stages,
prolonged fever, vomiting, constipation, some-
times diarrhea combined with tenesmus and often
mucus, and more rarely blood in the stools. Lo-
cally we find left-sided tenderness on palpation
and percussion, as well as rigidity in this region.

A distinct perisigmoiditic mass, which may be
sausage-shaped and correspond to the shape of
the sigmoid may form in a few days. Gurgling
may sometimes be demonstrated in this mass.
Such an exudate mass may regress or may form
an abscess in the left pelvis, and it may also per-
forate spontaneously in the intestine, in which
cases we find purulent and stinking stools. In
view of the great number of variations which the
sigmoid may assume we can easily see that the

254

ABDOMINAL PAIN

clinical picture will also be variable; for instance,
the mass may be placed horizontally and may be
pear-shaped, thus assuming the position of the
bladder. The perisigmoiditic mass need not al
ways be palpable through the abdominal wall but
may be found only on rectal or vaginal examina-
tion. The mucosa of the rectum or sigmoid may
even be fixed by the exudate, a sign seen on digital
examination. Endoscopy is also of value.

Of even greater frequency is periappendicitis,
in which the symptoms are most marked in the
left side. This may be due to complete or partial
congenital malposition, displacement of the ap-
pendix by adhesions, a congenitally long appen-
dix, or radiation or extension of the process to
the left. The diagnosis will be made on remem-
bering the possibility of such a condition, by find
ing that the objective signs are either most
marked or more concentrated in the right side,
and by absence of signs of sigmoiditis.

Another condition which is often not consid-
ered but which may cause pains on the left side
is obstruction of the inferior mesenteric artery or
vein. The obstruction of the inferior mesenteric
artery as a rule causes a severe infarction of the
intestinal wall and is followed by a fatal peri-
tonitis. Such obstruction of the inferior mesen-
teric vessels does not produce such stormy
symptoms, as these vessels have many collateral
branches, and the process may thus even heal

MESENTERIC ARTERY

spontaneously. Such a patient complains of a
very sudden, intense, cramp-like, recurrent pain
which lasts a few days. Collapse may appear,
as may pain over the descending colon, tenesmus,
and even pain in the transverse colon. Rigidity
over the above-mentioned places may also be
present, and there may be distention of the
affected regions and part of the intestines below
it. The latter is determined by inspection, rectal
examination, and sigmoidoscopy.

The mucosa may appear velvety and loose. Fe-
ver and peritonitic symptoms are absent. Micro-
scopic and occult blood in the stools will be of
very great value, but there may sometimes be only
occult bleeding with diarrhea. The diagnosis
can hardly be made in the absence of blood in the
stools, either microscopically or occult. We may
think of such an obstruction in the presence of
cardiac disease, especially of the heart wall, aorta,
portal vein, pre-existing infectious processes of
the intestine, general thrombophilia occurring in
general infections as influenza, and primary
nephritis or sclerosis of the interstitial blood
vessels.

Iliac pain on the left side may be referred
from the thorax. For a discussion of these the
reader is referred to the previous remarks on this
subject.

256

ABDOMINAL PAIN

Recurrent Paint in the Left Iliac Region

Our first consideration in the presence of this
kind of pain should be some intestinal disease,
especially the spastic conditions of the descending
colon, which may be a symptom of a spastic con-
stipation, mucous colitis, foreign bodies or para-
sites in the intestines, local infections, ulcers, ad-
hesions, etc.

It may also be of reflex origin, as from kidney
or gallbladder, or of central origin, as tabetic
crisis, or functional, as in nicotinism or neuras-
thenia. Such a localized spasm of the colon will
be characterized by recurrent colicky pains in the
left iliac region, sometimes very intense and often
nocturnal nausea, vomiting, constipation or reten-
tion of stools and flatus, and sometimes collapse.
We may find local meteorism, and we may be
able to palpate the descending colon and con-
tracted flexure as a tender cylindrical mass.
Papaverine and belladonna may cause relaxation,
and the X-ray findings will also be of value.

Simple intestinal colics such as stercoral or
flatus colics are seldom localized to this region.
Subacute and chronic ulcerations of the large in-
testines occur, such as dysentery, ulcerative colitis,
simple chronic ulcer of the sigmoid, and, occasion-
ally, simple chronic ulcer of the small intestines.

Peritoneal adhesions in the left iliac region are
of more importance as a cause of recurrent pai

PEBITOXEAL ADHESIONS 257

in this area. I wish to emphasize the fact that
peritoneal adhesions have certain favorite loca-
tions in the left as well as in the right iliac re-
gions. Both these regions may harbor the later
effects of any inflammatory process in the abdo-
men such as peritoneal exudate or any other con-
dition transported to the iliac regions by the intes-
tinal movements, gravity, and other causes. We
therefore often find adhesions in these places,
which adhesions may cause the recurrent pains,
although the primary cause may be elsewhere,
as in gastric ulcer, cholecystitis, periappendicitis,
parametritis, and appendicitis in which pressure
in the left iliac region usually causes pain in the
right side. Trauma, perforation, and perhaps
inflammations arising externally to the peri-
toneum may also cause these pains, as may stone
in the left kidney or ureter. Recurrent pyelitis
with recurrent pain and chills of several days'
duration occurs very often during or after preg-
nancy. There are also constipation, meteorism,
nausea, vomiting, and even slight abdominal ri-
gidity in this condition, and the pains may extend
high up to the lumbar region. Tenderness on
percussion and hyperesthesia of the skin over the
lumbar region are always present, but the positive
■urinary findings may be found only at intermit-
tent periods.

Such adhesions cause recurrent pains, a sensa-
tion of fullness or pressure in the left lower abdo-

258 ABDOMINAL PAIN

men, tenderness of this region, and emaciation.
The latter may lead us to mistake the condition
for malignant disease. The important point is
the fact that the pain is greatly increased by
movement of the bowels or upon bodily motion.
The course is chronic, and the location of the
symptoms is constant.

Stenosis from any cause must be suspected in
the presence of intermittent colics. In carcinoma
of the sigmoid we can occasionally palpate the
tumor itself. When a mass is felt it is usually
either the hypertrophic bowel proximal to the
tumor or this segment filled with scybala.

Furthermore, it is important to remember that
the sigmoid is the favorite place for volvulus. In
this disease, we find very intense pains of several
days' duration and not intermittent as in stenosis
colic, but rather remittent in character. There is
complete stoppage of the bowel for stool or flatus,
and there are meteorism and nausea.

Constant Sensation of Discomfort in the
Left Iliac Region

The same conditions which caused similar
symptoms in the right side may also cause the
same complaints in the left. For a consideration
of these the reader is referred to the chapter deal-
ing with that subject.

In addition I wish to mention that chronic
tuberculous perisigmoiditis may be the only local-

TUBERCULOUS PERISIGMOIDITIS

ization, either clinically or anatomically, of a tu-
berculous peritonitis. The patient complains of
a constant discomfort in the left iliac region, dys-
pepsia of the stomach and intestines, often dys-
uria, and night sweats, Objectively, we find sub-
febrile temperature and a tender perisigmoid
exudate mass on palpation or rectal examination.
The differential diagnosis between a simple and
a tuberculous perisigmoiditis will be made on the
history and tuberculin reaction. In the simple
type there are acute or severe pains in the begin-
ning, while in the tuberculous type the onset is
gradual and there may be tuberculosis in other
places. Luetic perisigmoiditis and sigmoiditis
may also cause this pain. Here the history, the
presence of lues elsewhere, nocturnal occurrence,
Wassermann reaction, and the effect of the treat-
ment may be of value.

Pains in the Lumbar Region, Flanks, and
Lateral Parts of the Abdomen

Lumbar Pains

In this chapter we will discuss pains in the real
lumbar regions and not in the median or lateral
portions of the body. When a patient complains
of a sudden, severe, colicky, or crampy pain in
the lumbar region our first thought is, of course,
of some involvement of the renal region.

Among the many conditions of the urinary sys-
tem which may cause such pains are stones in the
kidney or ureter. In ureteral stone the pain is
localized rather to the side of the flank part of the
abdomen. Oxalate stones produce the severest
pains, while phosphatic stones produce a more
constant pain with transient exacerbations. Urate
stones produce comparatively mild pains. It is
not necessary to consider that a large stone is the
only causative factor in colic and hematuria, as a
small sharp crystal such as oxalate may cause
similar results.

Renal colics are characterized by the uni-
lateral distribution, which distribution does not
necessarily correspond to the location of the stone,
as a stone on one side may cause pain on the

KKXAL COLICS 261

other by the renorenal reflex, while there may
be no pain at all on the affected side. The pains
typically radiate down the ureter to the bladder,
testicle, penis, labia or vagina. We also find
radiation down the lateral and anterior surface
of the thigh. Radiation towards the shoulder is
exceptional. The pains remain for hours or days,
sometimes with slight remissions. The pains are
often influenced by external factors, such as shak-
ing up of the body or the taking of acid foods or
drinks. They are sometimes relieved by elevation
of the pelvis, chills are often observed in the
beginning, and fever is absent when there are no
complications. Reflex vomiting occurs but is
without any effect on the pains. There may be
complete stoppage of stools and flatus; painful
meteorism, which may be partially relieved by
passage of flatus which may be present. Rectal
tenesmus, retention of urine, or desire to urinate
frequently, even when the radiating pains do not
reach the bladder, may also be found. The attack
may end abruptly.

Objectively we find hyperesthesia of the skin
In the lumbar region and tenderness on pressure
in the flanks and lumbar regions, especially at
the twelfth rib; the kidney, ureter, and sur-
rounding tissues may be tender on bimanual
palpation, while tenderness on percussion of
the renal region is often marked but may also
be absent. The testicle or ovary on the same

262 ABDOMINAL PAIN

side is tender. The former may be drawn up
by reflex contraction of the cremasteric mus-
cle, there is unilateral lumbar rigidity on the
diseased side, and the region of the iliohy-
pogastric nerve shows lessened sensibility, or it
may even be anaesthetic. The urine may be di-
minished and concentrated during the attack,
while the quantity is greatly increased after the
attack has passed. The urine is highly acid and
there are traces of albumin and occasionally mi-
croscopic hematuria, but there are at least a few
laked blood cells in the centrifuged sediment un-
less there is a complete obstruction of the ureter,
a condition which occurs especially after shaking
up of the body, as after riding, etc. There is
sometimes a large amount of urate or oxalate
crystals or gravel in the urine.

An affection which may resemble the condition
just described is tuberculosis of the urogenital
system. Tuberculosis of the kidney may cause
exactly the same kind of attacks as renal stone
when there are clumps of pus, blood clots, or
cheesy particles. Acute congestion of the kidney
or tension of the capsule in renal tuberculosis
may also produce colicky pains in the lumbar re-
gion but usually without radiation. The urine
may be absolutely clear in these cases, and only
animal inoculation for the presence of tubercu-
losis bacilli and cystoscopic examination may clear
up the diagnosis.

Wli

the sy

HEMATURIA

263

When hematuria is present the sequence of
the symptoms is of a certain importance, as in
renal stone the hematuria follows the colic, while
in tuberculosis the reverse is true. Furthermore,
tenderness of the testicle speaks rather for renal
stone. In cases in which the urine is cloudy or
intermittently so, and acid in reaction, we must
suspect tuberculosis of the kidney even when
there are no subjective complaints and the gen-
eral condition is good. A few red cells are pres-
ent in the urine even if there are no other abnor-
mal contents; in other cases a cloudiness caused
by pus cells or thin threads of blood in the urine
is present. Cultures of this urine on the ordinary
media will be sterile in spite of the many pus
cells which are present, and tuberculosis bacilli
may be found, but should be controlled by animal
inoculation, as the smegma bacillus may be very
easily mistaken for it. X-ray, cystoscopy, and
ureteral examination will be of great importance.

The patients may complain of only slight dysu-
ria or frequent urination at night, or may even
show no symptoms at all. Slight subfebrile tem-
perature may be present, as well as loss of weight
and lowered blood pressure. The diseased kidney
may he enlarged and tender, but we must remem-
ber that the opposite kidney may be tender and
swollen as a result of compensatory' enlargement.
It is also of great importance to examine the
ureter for thickening of the genital organs for

tuberculous changes. The tuberculin reaction
is of some value but may be misleading, as tuber-
culosis and stone in the kidney is not a rare com-
bination.

The mere finding of a renal stone should not
satisfy us, as we must determine the pathological
condition of the kidney itself, really the impor-
tant thing. We must remember that tuberculosis
may be present with a stone, and that a uric
acid stone is often associated with a gouty diath-
esis, and also that a renal colic with radiation may
occur in gouty diathesis «ven in the absence of
a stone, being caused by a deposit of uric acid in
the kidney. Congestion of the kidney and ten-
sion of the capsule may be the cause of pain in
the former condition. As a matter of fact, this
congestion and tension may cause renal colic when
they arise from any reason whatsoever.

Less common causes of lumbar pain than stone
and tuberculosis are certain types of nephritis.
The first is the acute hemorrhagic nephritis in
which the acute and rapid congestion of the kid-
ney, tension of the capsule and possibly angio-
neurotic spasms, may lead to repeated attacks of
colics with short intervals. Radiation of the pain
to the testicle may be present, but the pains do
not radiate along the ureter. The diagnosis in
the majority of cases will be based on the bilateral
character of the pains and hematuria. The hem-
aturia may be profuse or there may be only some

red blood cells and casts in the urine. In contra-
distinction to renal stone, the red blood cells in
the urine and the hemoglobinuria will be present
also during the intervals between the attacks.
The differential diagnosis will be especially diffi-
cult if it is localized to only one kidney, as un-
doubtedly does occur. The presence of the acute
edema, due to the nephritic changes, and X-ray
ureteroscopic examination will be decisive. There
is a type of nephritis, nephritis dolorosa, in which
unilateral attacks of pain are observed. We find
oliguria or anuria and disturbances of the kidney
function in these cases.

The differentiation or periappendicitis with red
blood cells in the urine has been given elsewhere.

Chronic colicky nephritis may cause intense,
typical renal colics with radiation to the testicle,
without previous symptoms or blood in the urine,
and with no changes in the urine except traces of
albumin, a few red cells, and some granular casts.
The acute edema of the kidney with resulting ten-
sion of the capsule may be responsible for the
pains. The diagnosis is made by exclusion of all
other diseases.

Ordinary chronic nephritis may occasionally
show typical colic, even combined with fever, and
is produced by intermittent renal congestion or
by passage of blood clots.

Acute renal congestion in malaria and reno-
typhoid, which is a form of typhoid appearing

as an acute hemorrhagic or non-hemorrhagic
nephritis, may also have to be mentioned. The
pains in these conditions are, as a rule, dull and
may set in suddenly in both lumbar regions with
colic. Similar symptoms may be present in gen-
eral sepsis with colon bacilli.

Congenital cystic kidney may often produce
symptoms later in life without previously causing
any trouble. These patients usually show the
typical picture of chronic interstitial nephritis
with cardiac hypertrophy, increased blood pres-
sure, even uremia, and sometimes colicky lumbar
pains with hematuria. The proof lies in finding
a large bilateral mass which feels like a bunch of
grapes and which corresponds to the kidneys.
There may be cysts in the liver or testicles.

Another rare condition to be mentioned is the
so-called perirenal hydrophrosis or an accumula-
tion of serous fluid between the renal cortex and
the tunica fibrosa.

Acute pyelitis causes colicky pains in the lum-
bar region but is without radiation along the
ureter. This occurs especially in pregnancy and
shows the intermittent colicky pains, chills and
fever, or fever without pains. There are also
intermittent cloudy urine which is acid in reac-
tion, intermittent leucocyturia, epithelia and bac-
teria in the urine, sometimes polyuria, and oc-
casionally H 2 S in the urine. Deep percussion
over the kidney causes pain, in contrast to peri-

HYDEONEPHHOSIS 207

renal inflammation, in which condition this sign
is always present. There is hyperesthesia of the
skin in the lumbar region and tenderness of the
anterior wall of the abdomen over the region of
the renal pelvis, the kidney may be palpable as
a tender tumor, the right side of the diaphragm
remains high, respiration is painful, and symp-
toms of general sepsis with vomiting may appear.
Caked pus in purulent pyelitis may also be a
cause for colic. This pyelitis may or may not
be tuberculous in nature.

Hydronephrosis may cause these pains in sev-
eral ways. A distended hydronephrotic sac,
after emptying, may quickly fill up again and
thus cause pain by a too abrupt refilling. An-
other cause is a change from an open to a closed
hydronephrosis, namely, from one in which there
is a communication with the ureter to one in which
the ureteral exit becomes blocked. Intermittent
hydronephrosis may be caused by a tumor of the
renal pelvis or of the kidney itself, in which cases
the pains appear when the body is in a certain
position, as for instance, in the upright position,
only to disappear when the position is changed.

A tumor of the kidney may cause pain in sev-
eral ways; there may be bleeding in the tumor
tissue, blood clots in the ureter, extension of the
tumor in the renal vein followed by thrombosis
of the latter, distention of the pelvis either by
the tumor itself or by its bleeding into the pelvis.

268 ABDOMINAL PAIN

particles of the tumor in the ureter, congestion of
the tissue which has a rich blood supply, followed
by a stretching or even rupture of the capsule,
metastasis in the opposite kidney, or a possible
combination with stone or tuberculosis.

Kchinococcus of the kidney with rupture into
the pelvis and wandering of the daughter cysts,
repeated ureteral colics with perhaps previous
finding of a cystic tumor in the renal region, which
later shows appreciable decrease in size with
milky or soapy urine containing cysts, hooklets,
or parts of the membranes may cause these pains.
The appearance of an urticaria with the initial
attack is a valuable sign, as are eosinophilia and
the serological findings.

Repeated embolic infarcts followed by fibrous
paranephritis may produce recurrent, intense
pains in the lumbar region especially in the region
of the iliohypogastric nerve. These attacks are
not unlike the real colic of kidney stone. We
also find constant, dull pain in the lumbar region
in these cases, which is increased on bodily mo-
tion or after hematuria. Radiation of the pain
along the ureter does not occur. The presence
of a possible cause for such an infarct, as in aortic
insufficiency, must also be looked for.

Fibrous adhesions between the kidney and
other parts may cause colicky pains in the lumbar
region, especially in neurotic people. The diag-
nosis can be made with some probability when

niSEASE OF THE URETEB

there is a causative factor such as luetic parane-
phritis, actinomycosis, or any inflammatory con-
dition of the kidney or surrounding tissue or
organs.

Primary disease of the ureter is usually accom-
panied by pain which is located in a more lateral
position than in kidney lesions and is distributed
along the course of the ureter, but in some cases
it may also cause lumbar pains which may be
more severe in the back and may even radiate
along the spermatic vessels to the testicle.

In the first place, we must mention real stenosis
colics of the ureter which may be caused by the
factors already mentioned and in addition by
scars resulting from ulcerations of a stone. The
diagnosis will be made on the X-ray findings,
cystoscopy, and urinary and ureteral examina-
tion.

Tuberculosis of the ureter can hardly be diag-
nosed with certainty. We may suspect such a
condition if we can palpate the ureter as a thick
cylindrical strand either by abdominal, vaginal,
or rectal examination. Cystoscopy may reveal
tuberculous lesions at the orifices of the ureters.
We must remember that a tuberculosis in the
renal pelvis may be the source of caseous masses
which, on passing down the ureter, cause severe
colic, although the ureter itself is not diseased.

Ureteritis membranacia may produce such
pains during the passage of pieces of the mem-

270 ABDOMINAL PAIN

brane down the ureter. The urine may contain
such pieces. This condition may occur in fibrin-
ous ureteritis with passage of fibrin clots, the
fibrin may be precipitated from the blood after
a trauma, or the membrane may be of mucus or
diptheritic character.

Chyluria is associated with similar symptoms
and signs. It may also be symptomatic as in
tuberculosis of the urogenital system, or it may
be an extension from the renal pelvis as in leu
coplakia or pseudomembranous inflammation of
the pelvis. In the first condition we find white
mother-of-pearl-like membranes with silicate
crystals, while in the pseudomembranous type the
urine contains masses of fibrin, uric acid crystals
and B. coli.

Torsion or kinking of the ureter may cause
severe pains, probably as a result of twisting of
the renal vessels and nerves. The picture may
be severe or may resemble ileus, but there are also
comparatively mild cases. We find severe ure-
teral colics with marked oliguria and sometimes
reflex or mechanical anuria with increased urinary
output after the attack. Red cells, albumin, and
leucocytes may be present, and the urine may be
concentrated. There may be an increased output
of urine after the reflex anuria just described
with resulting hydronephrosis or intermittent
hydronephrosis if the torsion or kinking still per-
sists. We will have to bear this possibility in

COMPRESSION OF URETEH 271

mind in the presence of a wandering kidney.
Before diagnosing such a kinking or torsion in
a wandering kidney we must first rule out a pri-
mary disease of this organ as a cause for the
pain. In tliis connection it is important to re-
member that if the pain disappears after replace-
ment of the kidney and assumption of the dorsal
position the condition is probably some pri-
mary disease rather than a torsion or kinking of
the ureter. It must also be remembered that
combinations of primary renal disease with tor-
sion of the ureter are not rare. Abnormal course
of the ureter due to congenital displacement may
also cause such pains.

The pains under discussion may also be caused
by compression or distortion of the ureter from
the outside. The most frequent of these condi-
tions is inoperable carcinoma of the uterus with
ensheathing of the ureters in the carcinomatous
mass. Such a carcinoma extending into the blad-
der, or even a primary bladder carcinoma, may
cause such compression near the entrance of the
ureters into the bladder. Tumor of the glands
near the ureters may also cause compression, as
may tumors or abscess of the bones, aortic aneu-
rism, or chronic inflammatory or fibrous processes
around the ureter, the so-called periureteritis exu-
dativa or adhesiva which may occur after an
appendicitis.

Our first thought in the presence of lumbar

272 ABDOMINAL PAIN

pains occurring in a patient with bladder disease
is of an ascending infection. Such lumbar pains
may occur by the vesicorenal reflex in strictly lo-
calized bladder, prostatic, or posterior urethra
disease. We find such a condition in stone or
tumor of the bladder, in passage of clots of any
kind through the urethra, or in chyluria. The
fact that these pains are bilateral may draw our
attention to the bladder, while the urinary find-
ings such as alkaline reaction and mucus in ab-
normal quantities will be of importance. "We
must not forget that acid urine is not rare in
cystitis and that alkaline urine may be found in
pyelitis. Mucus in the urine occurs chiefly in
cystitis but may also be present in pyelitis or rup-
ture of a congenitally cystic kidney into its pelvis.

Acute prostatitis or an acute exacerbation of a
gonorrheal prostatitis may also cause lumbar
pains, which may be unilateral, produce hyper-
esthesia of the skin, and tenderness on fistic per-
cussion in the lumbar region. This condition
may remain for several days and may even be
accompanied by chills and fever. The local
prostatic findings and the effect of treatment di-
rected to this part will clear up the diagnosis.
Stones in the seminal vesicles may very closely
resemble the attacks seen in renal calculus.

Among the extraurogenital conditions which
may imitate renal colic are cholelithiasis, acute
cholecystitis, and hepatic disease. The patients

CHOLELITHIASIS COLECYSTITIS

may complain of pain to the right of the spine,
in the neighborhood of the lumbar region instead
of in the usual location for this pain. There are
also patients suffering from gallbladder or gall-
stone disease in whom the pain appears repeat-
edly in the left lumbar region. This abnormal
location may be due to atypical radiation, spasm
of the colon, or hyperemia of the left kidney.
The pains may remain circumscribed or may ra-
diate towards the liver. The diagnosis during
the attack will be based on the findings of gall-
bladder or gallstone disease as already described
and on the negative urinary findings. Pain dur-
ing respiration points to liver colic in a limited
way, but this sometimes also occurs in renal
conditions.

The diagnosis during an attack will be very
difficult, as pains from renal stones may oc-
casionally radiate to the right shoulder. The
findings on palpation, the urinary findings which
occur in liver colic, and the nocturnal occurrence
of the attacks will speak for liver colic Increase
of the pain on bodily motion speaks rather for
renal stone. Hyperesthesia of the skin in the
lumbar region in cases of gallstones is located
above the twelfth rib, seldom going down so low,
while in renal stone the hyperesthesia reaches its
highest point in the region of the tip of the
twelfth rib and extends lower down. Hyper-
i of the skin in the anterior part of the

274

ABDOMINAL PAIN

abdomen is present in cholelithiasis but is absent
in renal stone.

We must not forget that renal colic may co-
exist with genuine liver colic or with pains aris-
ing from other organs of the digestive tract. We
can make the diagnosis only by a consideration
of all the above-mentioned points.

Right-sided lumbar pain in duodenal disease is
not so rare as is usually considered ; in fact it is
well to bear in mind the possibility of duodenal
ulcer as a cause for pain in this region. The
rigidity, tenderness on percussion in the right up-
per abdomen, and the other signs of duodenal
ulcer will clear up the diagnosis.

Acute yellow atrophy may also cause pain pos-
teriorly or even near the lumbar region. Acute
affection of the hepatic flexure or, more com-
monly, of the splenix flexure, such as pericolitis
or sudden stenosis, may lead to colicky lumbar
pains.

We must also consider renal neuralgia, either
from malaria, renal crisis of tabes, or hysteria,
or in conditions not at all involving the nervous
system but which are accompanied by hematuria,
as in nephralgie hematurique. The malarial neu-
ralgia will be characterized by its periodic course
and perhaps hematuria. In tabes the very in-
tense colicky pains may radiate along the ureters
into the bladder and urethra. Nephralgie hema-
turique is not a distinct condition and can hardly

LUMBAB REGION 275

be diagnosed with certainty. The complaints due
to a wandering kidney in hysterical patients may
be greatly exaggerated. Pains in the renal region
are also commonly present in sexual neuras-
thenia, spermatorrhea, and nervous impotence.
Here we find sacral pains radiating to the thighs
and rectal pains radiating to the renal region, or
even isolated pains in the latter place.

Chronic lead poisoning may occasionally set in
with pain in the lumbar regions, radiating to the
thighs, and the colic is localized around the navel
only later in the course. This abnormal location
of the pain may be due to particular involvement
of the renal vessels. Lead gout may occur in
these cases and produce renal colics, or the con-
dition may result from a chrome lead intoxication.

Acute Continuous Pain in the Lumbar Region

When a patient complains of a sudden pain in
the renal region which is continuous for a few
days and is boring, pressing, or sticking in char-
acter, but not colicky, and disappears after some
time, we must think of a renal infarct, especially
if there is a disease present which may cause such
an infarct. The conditions which are especially
likely to cause such an infarct are mitral stenosis,
aortic insufficiency, and, less often, changes in
the heart, aorta, or pulmonary veins or throm-
bosis of a peripheral vein with an open foramen
ovale in the heart. The pains in renal infarct

276 ABDOMINAL FAIN

are sometimes combined with chills and vomiting
and are usually circumscribed, with no radiation
or only slight radiation to the thigh. We find
tenderness on percussion and pressure in the
flanks and lumbar region as well as hyperesthesia
of the skin in these places. The patient suffers
from dysuria or he has a slight urinary incon-
tinence. An abnormally frequent desire to uri-
nate is usually absent. The urine may contain
excessive albumin, perhaps twenty per cent.,
which may quickly disappear. There is almost
always nephritic sediment and hematuria, al-
though they may be demonstrable only micro-
scopically. The finding of blood pigment in the
urine is of some importance; it may even be in-
tracellular. Fever of a few days' duration speaks
rather for an infarct than for renal stone. The
blood pressure is not increased, in spite of the
pain.

Sudden, continuous pain may also be caused
by an acute nephritis, less often by an exacerba-
tion of a chronic nephritis. Other causes are renal
abscess, either single or multiple, which are
caused by trauma or hematogenous infection,
acute pyelitis, and suppurated hydro- or pyo-
nephrosis. In all these conditions the pains are
localized strictly to the lumbar region and not the
flanks. The local tenderness on percussion or
pressure, as well as the skin tenderness, are chiefly
localized to the lumbar region and are hardly at

277

rNEPHHITIS
all present in the flanks. The tenderness may
be more pronounced in the anterior abdominal
wall over the renal pelvis than in the flanks.
There may be positive findings on palpation in
some cases. The objective findings in the urine
will be positive in nephritis, while the urinary
changes may be easily overlooked in pyebtis, and
a diagnosis of lumbago may be erroneously made.
There may be only traces of albumin, a few poly-
nuclear leucocytes, some laked red blood cells,
and uric acid crystals in the urine. Pyuria will,
of course, be well developed in pyelitis of a se-

Ivere grade when a renal abscess bursts in the pel-
vis, but in the absence of such an abscess's burst-
ing in the renal pelvis there will be only micro-
scopical pyuria.
The simple, active hyperemia which may occur
in acute infectious diseases or during an acute
exacerbation of a chronic infection will be fol-

I lowed by only mild pains in the lumbar region.
Traces of albumin and a few red cells in the
sediment may be present.
Similar moderate lumbar pains may also be due
to hydroureter. The rupture of a hydronephrotic
sac in the retroperitoneal tissues with urinary
infection may cause a sudden, very intense pain
in the lumbar regions and flanks, meteorism,
vomiting, singultus, no passage of stool or flatus,
reflex muscular rigidity, and very severe local
tenderness, the entire picture resembling that of

278 ABDOMINAL PAIN

pseudoperitonitis. Such a rupture of a hydro-
nephrotic sac may occur spontaneously or as a
result of a trauma with some blunt object. The
differentiation of such a rupture from intraperi-
toneal affections will be very difficult. The
knowledge of a previously existing, movable,
fluctuating tumor in the flanks, with hallottement
and anuria and the finding of hematuria, slight
fever, and increased pulse rate may support the
diagnosis. It may be added that such a rupture
of the renal pelvis need not be preceded by a hy-
dronephrosis but may be due to erosion of the
kidney pelvis by a renal stone.

Acute posterior paranephritis may be asso-
ciated with pains in the lumbar region. The se-
verity of the pains increases for a few days and
then remains very severe. Fever, repeated chills,
and a general septic condition occur in purulent
paranephritis. A single initial chill may also oc-
cur in non-purulent paranephritis. We find a
very marked tenderness on pressure and percus-
sion in the region of the twelfth rib, the pains are
strikingly increased on bodily motion, and the
spine is rigid. The lumbar muscles on the af-
fected side are rigid, the psoas may be contracted,
and there may be a local swelling or edema of the
skin and sometimes deep fluctuation. The urine
may be negative or may contain a few laked red
cells and bacteria. Similar symptoms may be
found in psoas abscess, or this abscess may per-

HEMOGLOBIN UBIA 279

forate in the paranephritic tissues and cause the
symptoms just described.

Hemoglobinuria may be associated with lum-
bar pains which are, as a rule, rather moderate.
The patients with paroxysmal hemoglobinuria
often complain of moderate pains in the lumbar
region and sometimes of a burning or tearing
sensation in this region ; occasionally the pain may
resemble that of renal colic. We find marked
tenderness in the lumbar region in the latter type
and only moderate tenderness in the usual form.
Headache and muscular pains may also be pres-
ent during an attack. The history of a provoca-
tive factor, urinary findings, diminished resist-
ance of the red cells to hypotonic solutions, and
reaction to the Donath'Landsteiner test will sup-
port the diagnosis.

Similar complaints may be present in hemo-
globinuria due to other causes, such as after blood
transfusion and blackwater fever, or may occur
in the course of acute infectious diseases. The
above-mentioned causes which may produce
hemoglobinuria may also produce signs of renal
involvement such as moderate albuminuria, gen-
uine casts, etc. These may be temporary or per-
manent and may occur in the infectious diseases
such as septic angina, etc.

Hematoporphyrinuria from any cause may
also be followed by lumbar pains and pains in
the bladder region above the symphysis. The

280 ABDOMINAL PAIN

diagnosis will be made on the reddish-black color
of the urine and on its chemical and spectroscopic
characteristics. Hematuria may appear as the
only sign of hemophilia and may be accompanied
by severe, sharp lumbar pains.

Similar bilateral lumbar pains have been ob-
served in parasitic chyluria. The diagnosis will
be based on the history, eosinophilia, filaria in the
blood, fibrinous clots in the urine, and milky as-
pect and the presence of albumin and many fat
droplets in the urine.

Inflammation of the retroperitoneal tissues,
even if purulent, produces pains which are usu-
ally dull in character. These inflammations may
arise from inflammation of the organs in the
lower abdomen or pelvis and lower extremities,
and only exceptionally from organs above the
diaphragm or within the peritoneum. The diag-
nosis of this condition will be made on the general
symptoms of suppuration or inflammation, such
as irregular fever, clouding of the sensorium,
moderate cyanosis, moderate increase of the pulse
rate to about one hundred, with some irregular-
ity, moistness of the tongue, and absence of ab-
dominal tenderness or rigidity of the psoas.
Marked meteorism, due to intestinal paresis, may
be present in spite of the fact that good results
are obtained with an enema. We find local edema
of the lumbar skin, with occasional bulging in this
region. There is often local tenderness on per-

UYEK— SPLEEN — KIDNEY

281

cussion or pressure, which tenderness extends
from the eleventh rib to the ilium, in contradis-
tinction to the renal tenderness, which is more or
less localized to the region of the twelfth rib.

Other causes of such lumbar pain are sub-
phrenic suppuration or abscess of the liver, spleen,
other organs near the pancreas, or the pancreas
itself. These pains may also be present in pan-
creatic necrosis if a walled-off abscess develops in
the left lumbar region. An abscess of the head
of the pancreas not infrequently leads to a gravi-
tation abscess which reaches between the gall-
bladder and right kidney and leads to an acute
anterior paranephritis. Acute adrenal disease
may also cause lumbar pains. In all the condi-
tions mentioned in this paragraph the pains may
be dull or very severe.

When a patient complains of sudden, intense
pain in the lumbar region, especially on the left
side, we must think of a possible angina pectoris
subdiaphragmatica. The lumbar pains are usu-
ally a radiation from the chest. The diagnosis
will be made on considering the origin of the
pains, the general features of an attack of angina
pectoris which may be present, and the findings
of arteriosclerosis. There are, however, cases in
which the pains in the lumbar region predomi-
nate or are limited to this region and which may
radiate even to the testicle or thigh.

Acute diaphragmatic pleurisy may also cause

283 ABDOMINAL PAIN

lumbar pains and vomiting, but will be differen-
tiated by the presence of dyspnea, singultus,
typical tender points of the phrenic nerve, and
negative findings in the internal organs. Acute
empyema, pneumonia, and chronic adhesive pleu-
risy may cause similar pain, even with hyper-
esthesia of the skin in the lumbar segments. This
localization may be due to radiation or to involve-
ment of the intercostal nerves or compression of
them in cases of chronic pleurisy with contracted
adhesions.

Appendicitis and periappendicitis may cause
lumbar pains in several ways. This may be due
to an abnormal location of the appendix towards
the lumbar region or to an ascending para-
nephritis which extends from a retrocecal peri-
appendicitis via the lymphatics to the cellular tis-
sue. This paranephritis may even be the first
symptom of an appendicitis which has apparently
remained dormant up to this time. The left lum-
bar region may become involved in these cases
by a wandering of the process either along the
diaphragm or pelvis. Paranephritic symptoms
may, however, be present on the right side with-
out any apparent anatomical change about the
kidney. In some cases of appendicitis we find
renal signs and red blood cells in the urine which
are due to an ascending infection of the ureter
and kidney from the appendix. These symptoms
of hemorrhagic nephritis may clear up after the

PARAMETRITIS — THROMBOPHLEBITIS 28d

appendix is removed. An appendical abscess
may compress the ureter or may perforate into
the latter.

Parametritic inflammation may extend up-
wards in the same manner as in periappendicitis
and may also lead to perinephritic symptoms.
We must also remember the possibility of hem-
orrhage into the perirenal tissues, as in the form
which occurs in periarteritis nodosa or in adrenal
insufficiency of the acute type. The periarteritis
nodosa will also show a general picture of an
acute infection with sweats, fever, marked pains
in the limbs, sudden lumbar pains, and hematuria.
Small aneurismatic nodules may be felt in the
superficial arteries, especially in the intercostal
muscles.

We must also consider thrombophlebitis of the
renal veins or vena cava when we are presented
by sudden, intense lumbar pains. Affection of
the vena cava may be luetic in origin and may
clear up under specific treatment. Other causes
for lumbar pain which may even have an acute
onset are abscess of the muscles of the back or of
the lumbar spine itself. The fixation of the spine.
X-ray, and careful local examination will lead
to a diagnosis. We must not forget that the
cause may be in lesions of the cord, its coverings,
or spinal nerves.

In addition to the before-mentioned causes, we
must mention the simple lumbago. This may be

284

ABDOMINAL PAIN

unilateral or bilateral and may set in with acute
lumbar pain or fever. The pains may be so se-
vere that this condition and real stone may be
confused. Lumbago is often a symptom of a
general gouty condition, less often of a trauma
or myalgia. Of importance in the diagnosis of
lumbago is the fact that the pain is closely asso-
ciated with all bodily motion, especially in bend-
ing over and straightening up, but may also be
present upon mere shifting about in bed. The
pains are present on walking or standing and
nearly always disappear upon lying down. There
is marked tenderness in the back and lumbar mus-
cles. The tenderness in the traumatic type is due
chiefly to tearing or bleeding, the tenderness be-
ing localized to one spot. The tenderness of the
muscle will be especially marked if the muscle is
contracted. This contraction of the lumbar mus-
cle also occurs in renal stone, and the tenderness
in this condition may be so great that the renal
affection may be easily mistaken for lumbago if
the rigidity is also marked. There may also be
hyperalgesia in lumbago — a sign especially
brought out with the Faradic current. Faradiza-
tion of the muscle itself, however, produces a
favorable influence. The pains are not colicky
and do not radiate, nor are there urinary changes
or reflex symptoms from the gastrointestinal
tract. Constipation may be present but is due
chiefly to fear of pain.

NEURALGIA — LUMBAGO 285

Neuralgia of the posterior branches of the lum-
bar plexus may also cause lumbar pain. These
pains are usually dull, with intermittent exacer-
bations, but they are sometimes quite intense,
with radiation to the gluteal region. The pains
are increased on walking, standing, or straight-
ening up. Typical tender points are present
somewhat externally to the first three lumbar
vertebra? and also at the middle of the iliac crests.
Herpes zoster may occasionally appear in the af-
fected area. There is often a combination with
a similar process of the anterior branches. The
pains in these cases may also radiate to the lower
part of the abdomen, pubic region, external
genitalia, and sometimes the inguinal region of
the thigh. The typical tender points for this
condition are found at a point somewhat above
the external inguinal ring and another at the mid-
dle of Poupart's ligament. The testicle or labia
may also be tender, and herpes zoster may be
present in the inguinal region.

There is a combination of lumbago with lum-
bar neuralgia or sciatica. This is important to
remember because some authors consider this
combination as a neuralgia alone. In making
such a diagnosis of neuralgia, we must try to de-
termine the cause, especially if it is a genuine
type such as occurs in metabolic conditions, in-
fectious diseases or after a "cold." The disease
may be only symptomatic and may be due to com-

286

ABDOMINAL PAIN

pression of the nerves by inflammatory or neo-
plastic conditions of the meninges, spinal cord,
or retroperitoneal organs. The neuralgia may
be the only symptom of an underlying disease
and may set in either suddenly or gradually. The
primary type may lead to a reflex rigidity of the
lumbar muscles. The typical tender points are
absent in the symptomatic variety, but there is a
radiation along the nerves, and even though the
pains may be bilateral because the lesion is cen-
tral, the intensity is greater on one side than on
the other. The pains are increased on bodily mo-
tion, and they often disappear when the patient
is in a certain position. The spine becomes rigid
when the patient moves about.

The girdle pains of tabes may be localized to
the lumbar region and give rise to tabetic pseu-
doneuralgia. These pains are often combined
with tabetic, gastric, or intestinal crises. The
tabetic neuralgia may be intermittent with inter-
vals of complete relief, or there may be only a
constant dull pain with acute exacerbations.

The lumbar pains in the acute infectious dis-
eases may perhaps be explained by hyperemia of
the meninges of the cord or myalgia, and are usu-
ally found rather low down near the sacrum.

Disease of the bones, as of the vertebra? or ribs,
may also cause lumbar pains, but their origin in
these cases will be recognized by the local findings
and X-ray.

COLICKY PAINS

287

Chronic Recurrent Lumbar Pain

When a patient complains of recurrent col-
icky pains in the lumbar region or flanks, we
must consider those conditions already men-
tioned, as they may all recur several times. In
short, the recurrent attacks in the urinary sys-
tem will reappear if the original cause is still
present and the colicky efforts have been insuffi-
cient to eliminate this cause, or when the cause
itself recurs.

In pains in the left side we must also consider
chronic or recurrent stenosis of the intestine due
to organic or functional causes. The diagnosis
will be easy if we see a marked stiffening or
peristalsis of the intestine. The short duration
of the individual attacks, lasting but a few
minutes, will distinguish the intestinal from the
renal colic; in the latter condition the individ-
ual attacks are much longer, lasting even hours,
with undiminished severity. The sonorous tym-
pany on percussion in the corresponding region,
characteristic stool, and X-ray will aid in the
diagnosis.

Gastric ulcer with or without pyloric stenosis
may produce only lumbar pains, which are usu-
ally on the left side. There is often an accom-
panying epigastric pain, but the lumbar pains
alone may be present.

Periappendicitis, especially when due to a re-

ABDOMINAL PAIN

trocecal appendicitis, must also be considered.
This condition may produce pains exactly resem-
bling kidney colic or lumbar neuralgia, or con-
stant pressing pain in the lumbar region.

In the presence of moderate, recurrent, draw-
ing pains in both lumbar regions, we must think
of a paroxysmal hemoglobinuria. These pains
often appear as a premonitory symptom of an
impending attack. These premonitory symptoms
may also appear in the rudimentary cases in
which there is only paroxysmal albuminuria and
which only occasionally show its true hemoglobi-
nuric character by the appearance of hemoglobin
in the urine.

Recurrent pains not of a colicky nature may
be a symptom of recurring hemorrhage into the
perirenal tissue or in Addison's disease.

We must also think of an aneurism of the
abdominal aorta as a cause of lumbar pains on
the left side. Pains on the right side are more
rare. These pains may radiate in a girdle-like
manner towards the thigh or to the testicle. The
pains may be colicky, are increased on walking,
and are diminished while in certain stooping
positions.

The diagnosis will be based on the pres-
ence of an expansile tumor, abnormal murmurs,
and retardation of the radial and femoral pulse
as timed with the apex beat. Simple luetic ab-
dominal aortitis, really the basis upon which an

aneurism develops, may cause recurrent, colicky,
intense pains in the left lumbar region. These
pains may show a tendency to radiate towards
the chest, and only when they are very intense
wdl there be any abdominal radiation. The
pains are provoked by bodily motion, may show
a nocturnal tendency, and may remain for hours
without intermission. We may find a marked
pulsation and murmur over the aorta when the
patient is lying down or when he is in the up-
right position. Aneurism of the lower part of
the thoracic aorta may also cause lumbar pains
if the diaphragm is pushed down. These pains
are also on the left side.

Vascular changes in the renal vessels may
cause colicky pains in the lumbar region with or
without hematuria. The same changes in the
vessels supplying the muscles of the back may
also cause such pains and perhaps in the same
way as in intermittent claudication. These mus-
cular pains appear after the patient has been
walking for a considerable length of time and
may even become painful muscle cramps, or they
may be combined with a sensation of weakness
or stiffness in these muscles. The pain stops
suddenly when these muscles are relapsed, as, for
example, when the patient leans against a wall.

Primary or secondary diseases of the bones
have the striking peculiarity of producing
chronic, recurrent, lumbar pains, with intervals

290 ABDOMINAL PAIN

of complete relief lasting several days or weeks.
Finally, I wish to mention that lumbar pains
may occur in women during menstruation. This
is due to congestion of the kidneys which results
from the uterine congestion at this time.

Chronic, Continuous Lumbar Pain

The first group to be considered is the uro-
genital system. Chronic nephritis or orthostatic
albuminuria may occasionally cause moderate or
vague sensations of pressure in the lumbar re-
gions which may be somewhat increased in
severity by the intake of large quantities of fluid.
Intense pain is a rare finding in chronic nephritis;
when it is present together with signs of chronic
interstitial nephritis and hypertrophy of the
heart, I am more inclined to suspect the presence
of a congenital cystic kidney than of a plain
chronic nephritis.

Continuous, moderate, or very severe pains are
found in pyelitis, hydro- and pyonephrosis, renal
tuberculosis, chronic suppuration of this organ,
ecchinococcus of the kidney, and especially renal
tumor. Such continuous pains with blood in the
urine should always awaken our suspicion of a
tumor of the kidney. These pains may also ra-
diate to the gluteal region or to the thigh. The
pains remain even if the patient is at rest and
are especially severe when the neoplasm has per-
forated through the capsule and has involved the

TUMOB OF KIDNEY 291

surrounding tissues. The tumor may be primary,
in which case it is usually a hypernephroma and
one in which the cachexia may appear only later
in the course, or the growth may be secondary,
as from the testicle, prostate, uterus, stomach,
breast, or thyroid gland. The pains are most in-
tense in cases of secondary neoplasm, and the
radiation may be along the sacrum or posterior
surface of the lower extremity or even along the
ureter to the bladder. There is only one other
condition which may produce pains of such se-
verity and constancy in the lumbar region; this
is metastasis in the retroperitoneal glands. Neo-
plasms cause considerable hemorrhages, and par-
ticles of the tumor may be found in the urine in
rare cases.

Tuberculosis of the kidneys usually causes dull
pain in one or both lumbar regions, but the pains
may also be sharp if there is an accompanying
paranephritis. In some cases of tuberculosis of
the kidneys the pain is increased upon the pa-
tient's lying down in a warm bed and not as the
result of bodily motion. We may find abnormal
irritability of the bladder, such as frequent uri-
nation or polyuria, and intermittent cloudiness
of the urine. Fever, hematuria, pus cells in the
urine, and the other symptoms already mentioned
may be present.

The stones or deposits which lie in the renal
tissue and which are incapable of being moved

292

ABD0M1XAL PAIN

are the ones which cause continuous pains,
are also various intestinal disturbances in
form of renal disease, such as constipation, flatu-
lence, and meteorism. The pains are decreased
on the patient's lying down and are particularly
increased when the body is being jolted, as i
riding over a rough road, making quick
ments or jumping. There may be microscopic
hematuria and traces of albumin during these
transitory attacks, and the urinary findings may
again disappear when the pain is gone. The local
symptoms are already described and the X-ray
will differentiate this condition from inflamma-
tion of the kidney, pyonephrosis, neoplasm, and
tuberculosis.

Constant lumbar pain which may change in
severity and which is more common on the right
side may be caused by a movable kidney or
nephroptosis. I do not believe that the movable
kidney itself can cause such symptoms, but that
the pain is due to very slight torsion of the ureter
with resulting urinary stasis leading to increased
tension of the capsule. It may also be due to
the hypersensitiveness of the neurotic patient.

Chronic scar-like paranephritis, such as occurs
in multiple infarcts of the kidney in aortic insuffi-
ciency, less commonly after traumatic hematoma
or stone, may also cause such pains. These pains
niay radiate along the ureter to the hypogastric
region and are increased on motion and decreased

HEMATURIA — ANEURISM 293

when the patient lies down, especially on his ab-
domen. There may be various grades of hema-
turia, or the urine may remain normal. Chronic
nephritis may also be a cause of paranephritis.
Here we usually find constant, intense, unilateral
pain in the lumbar region, radiating especially
downwards to the thigh or bladder. We find a
constant microscopic hematuria and an intense
hematuria at the height of the attack-
Two rare conditions causing lumbar pains are
aneurism of the renal artery and chronic suppu-
rative actinomycotic paranephritis. The first
condition is characterized by constant lumbar
pain, a tumor in this region with indefinite pulsa-
tion, and hematuria which is often intermittent.
We shall especially consider this condition if a
pulsating tumor with intermittent hematuria ap-
pears after a trauma. Actinomycosis is charac-
terized by an infiltration of the skin over the
painful lumbar region, followed by softening and
fistula formation and the presence of the causa-
tive organism. We must also consider a possible
vesicorenal reflex from diseases of a stenosing
character in the genitourinary canal. Affections
of the retroperitoneal glands may also cause con-
tinuous lumbar pains. These gland affections
may be primary, as in lymphosarcoma, or they
may be secondarily involved by metastasis. The
pains are constant but vary in intensity in differ-
ent cases and may be the only symptoms of the

294 ABDOMINAL PATN

disease in these glands. The enlarged gl
may also compress the ureter and cause ureteral
colic with its typical signs, although there mar
be no enlargement of the glands at all.

Pancreatic cyst or carcinoma may cause dull,
constant lumbar pains which are located on the
left side in involvement of the tail and on the
right side in involvement of the head.

Bilateral lumbar pains may occur in diabetes
mellitus or insipidus. The causes may be over-
straining of the already weak lumbar muscles,
pancreatic disease, or renal involvement from the
overactivity in polyuria.

Pains high up in the lumbar region on the right
side may be due to cholelithiasis. These are
atypical pains which are constant, except that
they do not occur at night. The tenderness is
higher up than in renal lesions, not reaching down
so far as the tip of the twelfth rib. Biliary
cirrhosis and carcinoma of the liver may occa-
sionally cause such pains. These pains are espe-
cially increased when the patient stoops.

Bilateral lumbar pains which may be so severe
that the patient is unable to walk may be due to
Addison's disease. The pains are also present
under both hypochondrial regions, either ante-
riorly or posteriorly, as well as in the lumbar re-
gion. The other signs of Addison's disease, such
as chronic dyspepsia, asthenia, general weakness,
arterial hypotension, and pigmentation of the skin

ADDISON S DISEASE

295

and mucous membranes, may also be present.
Affections of the adrenals, sucli as tumor or bilat-
eral or unilateral tuberculosis, may also cause such
symptoms. We must think of adrenal disease in
the presence of bilateral pain of the lumbar region
which radiates upwards with signs of adrenal in-
sufficiency and with no positive findings of renal
disease. Renal succussion may be present, and
tenderness along the ureter may also be found.
There need be no wasting away in adrenal dis-
ease of any nature; on the contrary, the fatty
tissue may be well preserved.

Unilateral pains in the left lumbar region, or,
more accurately stated, in the left lumbar and
flank regions, may be caused by affections in the
bowel, especially at the splenic flexure. Pain
may be present in this location in the flexure, as
from a carcinoma, or the pain may be referred
from some other place. Carcinoma causes a dull
pain in the left flank. This part of the bowel may
be the seat of pain which is caused by adhesions
either posteriorly upwards with the diaphragm,
or with the lateral abdominal wall. Adhesions
will also produce tenderness in the region of the
pain. Disturbances of the bowel movements, as
constipation, diarrhea, or both in alternation, his-
tory of a possible cause as trauma, intra- or re-
troperitoneal inflammation, or serositis in some
other location, as well as negative findings else-
where, may lead to the diagnosis. Occult or man-

396 ABDOMINAL PAIN

if est malena usually means tumor in this region,
but we must also remember that adhesions may
produce this sign as a result of stenosis, perhaps
intermittent* during which a distention or de-
cubital ulcer develops in the bowel. Further-
more, in cases where the pain and tenderness are
in the splenic flexure we may be dealing with a
lesion lower down in the intestine, causing only
distention pains at the splenic flexure. The X-ray
will be of great value in the diagnosis of this
condition.

The same remarks may be made relative to the
hepatic flexure, except that the symptoms may
here be mistaken for gall-bladder disease.

Chronic appendicitis may also be a cause for
lumbar pain and is most commonly found on the
right side, though occasionally localized to the
left. It is only by the characteristic local findings
of this disease that we are enabled to make a diag-
nosis. Chronic enlargement of the spleen or wan-
dering spleen may also produce pain in the left
lumbar region* especially if the patient is in the
horizontal position.

We must think of distant causes for lumbar
pains. Such are the constant pains due to fibrous
contracted pleurisy with radiation of the pain even
to the sacrum. This pain may be very moderate
or there may be simply a disagreeable sensation
in this region. Similar symptoms may be found
in pleural irritation, adhesions, and tuberculosis

DISTANT CAUSES

297

of the lungs, especially in the presence of an ac-
tive process in the lower lobes. There is active
tuberculosis in the majority of cases, and I be-
lieve the cause is a toxic action or reflex contrac-
tion of the lumbar muscles, as we may find
tenderness on percussion or palpation of these
muscles.

Neurasthenic spinal irritation may be found in
ordinary sexual or traumatic neurosis. The pa-
tients complain of a continuous drawing or press-
ing pain which may vary in intensity, even
producing severe pseudorheumatic pains in both
lumbar regions with radiation to the sacrum.
These patients often think that they are suffer-
ing from renal or spinal disease and complain of
feeling as though their backs were broken. The
diagnosis is made on the presence of neurasthenic
stigmata and by exclusion of any organic disease.

Diseases of the spine such as marked kypho-
scoliosis may cause intense pain on the convex
side of the curvature. Affections of the cord,
meninges, skin, and nerves may all cause lumbar
pains. Lumbar pains may also be due to pos-
tural causes as in cases of flat foot. It must be
determined if the muscular disease is primary or
secondary to lesions in this vicinity.

Pain in the Flanks

This chapter will deal especially with pains
localized to tiie flanks. We must mention all the

298

ABDOMINAL PAIN

affections of the renal pelvis, ureter, dystopic
kidney, and periureteral tissues. The pains in
disease of the renal pelvis may extend anteriorly
from the flanks to the hypochondrium. The
other findings have already been described.

The large intestine is a much more frequent
cause of pain in the flank. The causes of intes-
tinal colicky pains in the flanks may be simple
intestinal colic of the ascending or descending
colon or the more common colic due to stenosis.

High rectal stenosis may cause pains which
are not definitely localized and may be felt any-
where along the large intestine, but the patient
complains of tenderness in the left flank. This
sign may be considered of the utmost importance
in high rectal stenosis even in the absence of
tenesmus or findings on rectal examination. The
other signs, such as gurgling, stiffening, and peri-
stalsis, may also appear and serve to distinguish
it from ureteral colic with constipation, meteor-
ism, and vomiting.

Recurrent colicky pains in the region of the
descending colon may be due to colonic spasm.
The X-ray is of value. A rubbery, hard, tender
strand about as thick as a thumb may be found.
Such a colonic spasm may be due to chronic
nicotinism, primary disease of the intestinal wall,
pericolitic adhesions, mucous colitis, foreign
bodies in the bowel, sclerosis of the intestinal
arteries, or general nervous causes. Such a

299

spasm may also be reflex as from Intense gall-
stone or renal colic.

If a patient complains of a single acute transi-
tory attack of pain in the flank, we must first
think of a catarrhal colitis and then of an ulcera-
tive process of the mucous membrane. The
nearer the ulcerative process approaches the se-
rosa, the more will the pain have a tendency to be
continuous. We will also find local tenderness,
constant gurgling over the region which is cir-
cumscribed, and often occult or manifest blood or
pus in the feces. The X-ray will also be of value.

Acute exudative pericolitis may also occur, es-
pecially at the ascending and descending seg-
ments and at the flexures. The changes are simi-
lar to those found at the cecum or sigmoid flexure
in similar changes at these places. These masses
of exudate may regress and disappear in a few
days, or, what is more rare, they may go on to
suppuration. The condition is characterized by
the onset of local pain at the site of the lesion,
nausea, vomiting, fever, constipation, and occa-
sionally diarrhea, except in those cases which de-
velop on the basis of an ulcerative colitis. There
is also a very tender, painful, round or cylindri-
cal tumor which is smooth and dull or dull tym-
panitic on percussion, thus resembling a periap-
pendical tumor. Such a tumor may develop and
disappear in the course of a few days. The most
severe degree of such a pericolitis is found in per-

300 ABDOMINAL PAIN

foration of the bowel into the retroperitonei
tissue, usually the result of a tuberculosis of th
large intestine.

Our knowledge of the pre-existing causatfr
condition in the bowel, sudden onset, sudden an
intense pain, septic fever, general condition c
the patient, and the local signs of suppuratio
will lead to a diagnosis. It will be difficult t
make a differential diagnosis between such
pericolitis, periappendicitis, and cholelithiasis un
less a palpable exudate mass is present. Thi
is especially the case in patients having 1 periap
pendicitis with pains high in the right flank a
the level of the navel. Such symptoms may als<
be caused by an appendix which is turned uj
anteriorly over the cecum.

We may have to deal with a serofibrinous,
purulent, or phlegmonous inflammation of the
retrocolic tissue, caused or possibly spread via the
lymphatic system. Such a condition is more fre-
quently found behind the ascending colon, less
often behind the descending colon. The mosf
common causes are inflammation of the female
genitalia or periappendicitis, less often from in-
flammations of the male genital tract. In addi-
tion, inflammation of the retroperitoneal tissue
may be caused by disease of practically all organs
in the small pelvis or retroperitoneal organs, 01
by tumors or cysts of such organs as the kidney,
pancreas, lymphatic glands, etc. Perforation of

KKTROPERITONEAL TISSUE

any part of the gastrointestinal tract or gall-
bladder into the retroperitoneal tissues, or exten-
sion of diseases from the before-mentioned organs
into the retroperitoneal tissues, may also cause
these symptoms. Inflammation of the posterior
mediastinum may extend downwards, and a sim-
ilar process from below may travel upwards.
The retroperitoneal tissues may also become pri-
marily involved or may be secondary to diseases
of the spine, ribs, pelvis, or muscles. Acute or
subacute inflammation of the psoas muscle even
without extension of the process may cause re-
ferred pains in the flanks and may be unilateral
or bilateral.

If the inflammation and suppuration is local-
ized behind the ascending colon, the pains are in-
tense only when there is a localized abscess forma-
tion with bulging in the flanks. Here we find
redness and edema of the skin over the involved
area. The pains may be absent or be only of a
mild oppressive nature if the exudate is serofibri-
nous or phlegmonous, or if the process extends
upwards behind the kidney and forms a sub-
phrenic abscess. The objective signs, when pres-
ent, are slight flexion and adduction of the thigh,
tenderness in the right flank, and tenderness only
on very deep pressure, so that the examiner
touches the posterior abdominal wall from the
anterior surface before the sign is elicited.

Rheumatic myalgia of the psoas muscle may

302 ABDOMINAL PAIN

cause pain in the flank with flexion and adduction
of the thigh and the other usual symptoms of
psoas abscess. The diagnosis can be made only
on exclusion of all primary and secondary dis-
eases in this region or psoas muscle, as well as
by the presence of myalgia in the neighboring
muscles.

Actinomycosis has the peculiar tendency to
extend into the retroperitoneal tissue just as it
does into the posterior mediastinum. It may ex-
tend along the spine or laterally along the iliac
fossre, thus imitating other inflammatory proc-
esses in this region. The suppurative process
may even extend downwards to the lower ex-
tremities.

We may consider retrocolic phlebitis in the
presence of phlebitis in the lower extremities with
subsequent pain in the flanks and edema of the
lower limbs.

Cholecystitis may cause such symptoms in low
position of the liver or gallbladder or abnormal
position of the latter to the right. We must also
consider disease in the external portion of the
right lobe of the liver, such as tumor, abscess,
gumma, etc. Perihepatitis, disease of Riedel'g
lobe, retroperitoneal vein, nerve, gland, or mus-
cle affection, and mesenteric cysts which are dis-
tinguished by the very marked and characteristic
mobility, especially towards the lateral parts of
the abdomen, must also be considered. We must

PAIN IN FLANKS 303

also think of disease of the iliac fossa or organs
located in this region, such as a loop of the small
intestine, tumor of the bowel, dystopic and path-
ologically changed ovary, or even the uterus.

I wish to mention another cause for pain in
the flank, even of colic, which may sometimes
extend along the ureter and which may lead to
the wrong diagnosis of appendicitis situated low
down, or of a high ureteral colic. This is ingui-
nal hernia. The examination of the inguinal canal,
presence of an open ring, and disappearance of
the pain upon application of a suitable bandage
will clear up the diagnosis. Extreme local relax-
ation of the abdominal wall, as after a poliomye-
litis, may give rise in this region to a hernia with
severe colicky pains.

Chronic, Continuous Pain in the Flanks

We find this type of pain in tumor and chronic
inflammations of the intestinal wall and either
the ascending or descending colon. This may
be tuberculosis, syphilis, actinomycosis, etc. We
may find such pains especially in tumors which
have not as yet led to a stenosis of the bowel.
This pain may also be caused by involvement of
the glands in this area by tuberculosis, tumor,
leucaemia, lymphogranuloma, or sarcoma, less
often by syphilis or simple inflammation secon-
dary to infection elsewhere. The diagnosis is
made on the finding of a tumor mass, enlargement

304 ABDOMINAL PAIN

of the glands elsewhere, or the presence of a pri-
mary cause which may extend to these glands.

The previously discussed pains in the lumbar
region, caused by pressure on the spinal roots of
the lumbosacral plexus, may also manifest them-
selves as pains in the flanks. These pains may
be very intense or continuous, or they may show
exacerbations. They may radiate to the genitals,
testicles, or inguinal region, or to the thigh. The
localized tender points already described, paras-
thesia, sensory and motor disturbances, especially
in the area of the crural nerves, flexion of the hip
joint, and the presence of a primary or metastatic
tumor or other compressing cause of the nerve
root will aid in the diagnosis. Disease of the
lower ribs, spine, iliac bones, or even the femur
may of themselves lead to pains in the flanks.

Lumbar Pain in the Middle Line

In this section I wish to discuss pain in the
middle line at the lumbar region and radiating to
both sides. The patients usually refer to these
pains as sacral pains.

We must first consider disease of the spine and
nearby ribs, such as caries, syphilis, actinomycosis,
neoplasm, infectious spondylitis, gonorrhea, os-
teomalacia, acute and chronic rheumatism of the
vertebral joints, rhizomely, and KiimmeVs dis-
ease. There are also affections of the spinal
canal, as of the cord, meninges and disease of the

PAIN IN MIDDLE LINE

305

abdominal aorta, coeliac plexus or artery, retro-
peritoneal glands or tissues, pancreas, duodenum,
mesentery, and, more rarely, renal or adrenal
disease. Most of these conditions have been de-
scribed in the chapter on nasogastric or sacral
pain.

I wish to point out that a retroperitoneal in-
flammation, suppuration or phlegmon may extend
upward from some pelvic affection but may oc-
casionally arise from a subphrenic focus or medi-
ally from a paranephritis towards the spine, even
crossing over to the other side. In renal disease
the presence of pain in the median line and ex-
tending to both sides must make us suspect a dis-
eased horseshoe kidney.

Pain in the Left Hypochondrinm

The chief cause of splenic pain is perisplenitis.
The patients complain of pain or stitch in the
left side on taking a deep breath, coughing, sneez-
ing, or walking. Objective examination may re-
veal local tenderness in the intercostal spaces over
the splenic region, and we may find a rub on aus-
cultation and also by palpation if the spleen is
enlarged. Such a perisplenitis may be the cause
for pains in this region in leucaemia, polycythe-
mia, syphilis of the liver, and pericholangitic cir-
rhosis of the liver. Perisplenitis is a common and
dominating symptom for a limited period in the
course of polyserositis when we find a perisple-
nitis without apparent cause.

Moderate pains or discomfort in the left hypo-
chondrium are felt if the splenic capsule is rap-
idly stretched by increase in size of this organ.
Such pains may be seen in acute infectious swell-
ing of the spleen, as in malaria or typhoid, but
is most marked in recurrent fever. It also occurs
during the attack in paroxysmal hematuria, acute
leucaemia, tuberculosis or syphilis of the spleen,
and rapidly growing tumors of this organ, as in
sarcoma, echinococcus, hemolytic icterus, etc

806

SPLENIC INFARCTS

The pains sometimes occur in chronic splenic
tumor, as in the various types of splenomegaly
or chronic typhoid or paratyphoid.

Splenic infarct may be followed by intense
pains in this region, radiating towards the left
shoulder, stomach, or left thigh. Chills and vom-
iting may be present. Since most splenic infarcts
are caused by acute or recurrent infectious endo-
carditis, it is evident that suppuration may occur
in some cases with resulting abscess formation.
A strikingly long duration of the pains with a
new exacerbation after the initial pain has begun
to subside, general symptoms such as chills and
fever and cytological and bacteriological as well
as blood findings, will enable us to make the diag-
nosis of abscesses. Acute myomalacia of the
heart may also produce splenic infarct, but the
symptoms will be mild and will be due to the re-
sulting perisplenitis rather than to the infarct
itself. Such a pain of perisplenitis may be the
first symptom of a cardiac lesion.

Other causes for splenic infarcts are recurrent
fever, acute leuceemia and pyemia. Causes for
splenic abscess are typhoid, pyemic metastasis, or
extension from a neighboring organ.

Splenic infarct is the usual cause for pain in
the splenic region in the presence of an acute
infectious endocarditis. Rupture of a mycotic
aneurism of a splenic artery, with bleeding into
the spleen, or rupture and bleeding into the ab-

308 ABDOMINAL PAIN

dominal cavity, may also cause pain in the left
hypochondrium. The latter condition will be
characterized by a sudden, overwhelming pain
in the left hypochondrium, with radiation to the
left shoulder, collapse, signs of acute internal
hemorrhage, and usually appearances of dullness
in the left side of the abdomen.

Rupture of the spleen may be caused by trau-
ma, but a diseased spleen may be ruptured by a
comparatively insignificant factor, such as cougr
ing or straining. The diseases in which such a
splenic condition may occur are typhoid, malaria,
or recurrent fever. A localized hematoma may
form if the rupture occurs in a previously walled-
off space as observed by me in a case of polycy-
themia.

Torsion of a wandering spleen may cause such
pains. They are very severe and are preceded
by crampy pains in the left hypochondrium.
There may be collapse, dysuria, and a palpable
tumor or resistance in the left part of the abdo-
men. The enormous enlargement of the spleen
in these cases is due to the torsion of the splenic
vessels and resulting obstruction to the return
flow of the venous blood. The most intense pains
I have ever seen in the splenic region were due
to total anemic necrosis of the spleen resulting
from an erosion of the splenic artery by a car-
cinoma of the small intestine.

Hemolytic icterus may cause pains as a result

SPLENIC VESSELS

of tension of the splenic capsule or by the hyper-
activity of the organ itself. We find moderate
or severe colicky pains at varying intervals.

Sclerosis of the splenic vein may cause inter-
mittent colicky pain, which may also be contui-
Iuous and which is found in polycythemia and in
some cases of splenomegaly. The pain may be
the only symptom for years of a diseased condi-
tion of the hematopoetic system. Arterial aneur-
ism of the splenic artery may also cause such
pains. The process may be mycotic or arterio-
sclerotic in origin. The pains in the presence
of arteriosclerosis may be due to infarcts in the
spleen from dislodged emboli coming from the
aneurismatic splenic artery.

Pain in the left hypochondrium may also be
due to adhesions between the spleen and abdom-
inal wall or stomach. Such adhesions can only
be diagnosed by the location of the pains and by
the presence of adhesions about the neighboring
intestines as evidenced by the presence of intes-
tinal stenosis colic.

New growths or inflammations in the splenic
region, such as circumscribed peritonitis from the
stomach, may cause pains in this region either by
their mere presence or by extension in the spleen
itself. Extension of a tumor or inflammation
into the spleen will be identical with the picture
produced by such primary condition in the spleen.
We find the typical localization of the pains,

310 ABDOMINAL PAIN

severe general course, local edema of the skin,
and a secondary pleurisy on the left side. These
pains are caused by thrombophlebitis of the splen-
ic vein, multiple abscess formation in the spleen,
erosion of the capsule, or growth through it into
the splenic tissue itself.

Chronic pain in this region may occur as a
result of stretching of the stomach wall after
meals when there is an obstruction at the pylorus
or duodenum. Periappendical suppuration may
extend upward to the left hypochondrium and
cause pain in this region.

Among the diseases of the colon which may
produce pain in the left hypochondrium is car-
cinoma of the colon extending into the parietal
peritoneum. Other possibilities are plastic colitis
with adhesions in the splenic flexure which pro-
duce a very tender tumor mass corresponding to
the shape of the colon, as well as nausea, vomit-
ing, and fever. Severe ulcerative colitis may lead
to pains in this region and is characterized by
fever of long duration, often for a month, severe
general symptoms, diarrhea and constipation, and
almost constant presence of mucus, blood, or pus
in the feces.

We must also consider the simple ulcer of
the colon, pericolitis, stenosis of the splenic
flexure from any cause, simple distention pain
caused by a stenosis lower down in the colon,
and adhesions. Such adhesions may be a result

SPLENIC FLEXUKE

of a peritonitis, as from appendicitis, or it may-
develop during the course of a subphrenic suppu-
ration, pleurisy, etc. The diagnosis may be made
on a history or presence of a possible cause, symp-
toms of stenosis colic of the intestine, and X-ray
which may show a marked, acute-angled kinking
of the splenic flexure with difficult or delayed
passage of the contents. There may be flatulence
or dilatation of the transverse colon or even a
pulling up of the splenic flexure towards the
spleen. The patients complain of increased pain
on bodily motion or movements of the diaphragm
as in coughing or sneezing.

Coloptosis may cause these pains by kinking,
in the manner already described. In these cases,
the symptoms are increased on bodily motion or
shaking and are diminished by application of the
proper abdominal support. Deep and glide pal-
pation according to the method of Hausamatin,
as well as the X-ray, will clear up the diagnosis.

Similar pain has been observed in colonic spasm
in the distal part of the transverse or descending
colon, or even in the sigmoid. These pains may
occasionally show a nocturnal tendency. Pains
in the left hypochondrium, due to distention of
the bowel by gas, will be relieved on passage of
flatus.

Pains in the left hypochondrium may also be
due to diseases of the left kidney, adrenal or tail
of the pancreas as well as to disease of the retro-

312

ABDOMINAL PAIN

peritoneal tissues. It is especially important to
know that pains from the left kidney may be
localized to or predominate in the left hypochon-
drium, extending even as far as the left border
of the epigastrium under the left costal arch.
The pains may radiate to the left thigh, and there
may be hyperalgesia of the skin along the border
of the left costal arch.

Pancreatic affections such as purulent and non-
purulent disease, which may be primary or meta-
static, as from an acute endocarditis, cesophageal
or retroperitoneal disease, may cause similar
pains, as may also the various affections of the
stomach. Acute boring or cramp-like pains mid-
way between the xyphoid and navel and extend-
ing from one costal arch to the other and into the
hypogastrium, especially the left, occurs in acute
pancreatic disease even if there is no evidence of
previous pancreatic insufficiency. We may see
premonitory, colicky pains whicli are mild and
of short duration and which may exist for years
before a precipitation of a real pancreatic attack
with collapse, etc., occurs.

Liver or gallbladder colic may be located in
the left hypochondrium, and the initial tender-
ness may also be there, but they eventually shift
back to the right side. The pains may, however,
be constantly present on the left side when there
are accompanying adhesions with the stomach
or omentum or if there is gastrospasm with re-

LTVEH — DI A PH H AU M

suiting gastric dilatation, and an accompanying
affection of the pancreas.

Affections of the left lobe of the liver, especial-
ly those leading to enlargement of this part, cause
pains in the hypochondrium, even more frequent-
ly than the diseases mentioned in the previous
paragraph. Such affections are gumma, neo-
plasm, cyst, etc.

In the presence of pain located somewhat
above the spleen and toward the diaphragm, we
must consider a subdiaphragmatic suppuration
or inflammation in the space bounded by the
spleen, diaphragm, left lobe of the liver, and
stomach. Such a subdiaphragmatic abscess may,
for example, result from a pancreatic necrosis,
or it may be the first localization of a tuberculous
peritonitis. In the latter condition, the patient
may complain of pain in the left hypochondrium
coming on acutely, dyspeptic complaints and sub-
febrile remittent or intermittent fever, without
other objective signs. Ascites and the other typ-
ical symptoms will eventually develop.

We must also consider affections of the dia-
phragm and of the diaphragmatic pleura, such
as diaphragmatic hernia, eventration, or pleurisy.
It is sometimes very difficult but important to
differentiate a pleural from a splenic rub. This
is best done by determining whether the point
of maximum intensity is over the pleura or orer
the area of splenic dullness. If there are two

314 ABDOMINAL PAIN

points of maximum intensity, we must consider
a combination of pleurisy and perisplenitis. Lo-
cation of the tenderness is also of great impor-
tance, as tenderness in the lower four intercostal
spaces in the axillary line and extending below
the costal arch points to the spleen as being the
organ at fault. It must not be forgotten that a
large spleen may cause compression atelectasis
of the overlying lung with resulting rales which
must not be confined with a perisplenic rub.

Constriction or compression of the intercostal
nerves by the scar tissue in fibrous pleurisy may
cause pains like those in diaphragmatic pleurisy.
Other involvements of the intercostal nerves, such
as genuine or symptomatic neuralgia or compres-
sion due to some other condition, may also cause
such pains.

Traumatic hernia, diseases of the skin, muscle,
connective tissue, etc., may cause pains in this
region. For a discussion of these see the descrip-
tion of these lesions in the chapter dealing with
pain in the right hypochondrium. Ptosis of the
spleen or left kidney must also be mentioned.

Bilateral Hypochondrial Pain

Our first thought in this case is colic of the
colon, resulting either from some simple cause or
from stenosis. In the latter instance, we must
consider a stenosis of the splenic flexure. We
must consider other diseases of the large intes-
tine, such as colitis, carcinoma, etc., either at the
transverse colon or at the flexures on either side.

Addison's disease, pelvic disease such as pros-
tatic carcinoma which may cause severe pains
radiating to both hypochondrial regions, and
cholelithiasis or cholecystitis with pains in both
hypochondrial regions, but with location of the
objective findings in the right side, must all be
taken into consideration. Bilateral hypochon-
drial pains may also be a symptom of affection of
the pancreas; this may be diffuse or simply a
stenosis of the lower end of the duct with limita-
tion of the process to the head. Symptoms of
pancreatic insufficiency as discussed in the chap-
ter on pancreatic disease will make the diagnosis

Such bilateral pains will also be present in
acute infectious diseases, with acute or rapid
enlargement of the spleen or liver and resulting

315

316

ABDOMINAL PAIN

abnormal tension of the capsules. This is present
in recurrent fever, Malta fever, and malaria.
These pains have also been met with in hemolytic
icterus and periarteritis nodosa.

Diaphragmatic trichinosis, neurosis, or over-
straining, as in running, coughing, etc., may also
cause such pains. Acute diaphragmatitis may oc-
cur in pneumonia or as an entity in itself. The
patients complain of more or less localized abdom-
inal pain which may be intermittent or continuous
and which may be localized in the epigastrium or
right hypochondrium and may easily be mistaken
for a gastric ulcer or cholecystitis. We sometimes
find girdle pains corresponding to the line of in-
sertion of the diaphragm. The pains run from
the front to the back, either on one side or bilat-
erally. We find a lagging or a portion of the
diaphragm on inspiration if the process is local-
ized, with an increase in the respiratory excur-
sion in the thoracic part above the region involved.
The X-ray will show limited excursion of the
affected part of the diaphragm.

Affections of organs located bilaterally, as in
bilateral nephrolithiasis, or tissues with a bilat-
eral distribution, as in subdiaphragmatic pleurisy,
may also be causes for bilateral hypochondria!
pain. We must also consider affections of the
intercostal nerves, muscles, and ribs as a possible
cause of such pains.

Pain in the Region of the Nave]

We must consider disease of the navel itself,
such as hernia, metastasis from elsewhere, and
pains arising around the umbilicus or from nearby
places.

Sudden, colicky pains around the entire cir-
cumference of the navel is a very common symp-
tom in colics from the small intestine. We may
have to deal with a simple colic from any cause,
flatulent colic, or the result of Schmidt's fermen-
tation dyspepsia. We must also consider lead
and stenosis colic

Colic due to disease of the colon may also be
distributed around the entire circumference of
the navel, especially if coloptosis is present. Such
pains are found in dysentery, ulcerative colitis,
and cholera ; rarely in mucous colitis.

A nervous enteralgia may also be localized
about the navel. The diagnosis will always be
very difficult, as we can hardly exclude all the
anatomical lesions, especially adhesions. On the
other hand, the hysterical stigmata or psychic
signs may he suggestive but are not conclusive.
The fact that the attack ends with dysuria, urina
spastica, the suggestibility of the patient, and

818 ABDOMINAL PAIN

the hyperesthesia of the skin over the painful
area, will speak for such a diagnosis.

It is well to remember that acute continuous
pain around the navel may be due to appendi-
citis or periappendicitis. There are a great many
cases in which the patient complains of very in-
tense pains around the navel during the first two
days; in other cases the chief area of pain is in
the epigastrium and only later at the navel. In
both instances, the pain finally wanders to the
ileocecal region after one or two days. There
are also comparatively rare cases of appendical
involvement with pain which remains about the
navel throughout the course. Chronic, dormant,
or recurrent chronic appendicitis may cause re-
current pain or soreness about the region of the
navel.

When a patient complains of apparently sim-
ple colic in the region of the navel, coming on
three to four hours after meals and accompanied
by marked constipation, loss of weight, and dys-
pepsia, we must think of chronic appendicitis.
Multiple perisigmoidal adhesions resulting from
periappendicitis may also cause pain around the
navel. In addition to the symptoms already de-
scribed for these diseases, we will also find pain
in the navel region by pressure over the appen-
dix and vice versa, as well as by inflation of the
rectum.

Acute destructive appendicitis may cause pain

SPLENIC VESSELS 309

of tension of the splenic capsule or by the hyper-
activity of the organ itself. We find moderate
or severe colicky pains at varying intervals.

Sclerosis of the splenic vein may cause inter-
mittent colicky pain, which may also be contin-
uous and which is found in polycythemia and in
some cases of splenomegaly. The pain may be
the only symptom for years of a diseased condi-
tion of the hematopoetic system. Arterial aneur-
ism of the splenic artery may also cause such
pains. The process may be mycotic or arterio-
sclerotic in origin. The pains in the presence
of arteriosclerosis may be due to infarcts in the
spleen from dislodged emboli coming from the
aneurismatic splenic artery.

310 ABDOMINAL PAIN

SPLENIC FLEXURE

311

of a peritonitis, as from appendicitis, or it may
develop during the course of a subphrenic suppu-
ration, pleurisy, etc. The diagnosis may be made
on a history or presence of a possible cause, symp-
toms of stenosis colic of the intestine, and X-ray
which may show a marked, acute-angled kinking
of the splenic flexure with difficult or delayed
passage of the contents. There may be flatulence
or dilatation of the transverse colon or even a
pulling up of the splenic flexure towards the
spleen. The patients complain of increased pain
on bodily motion or movements of the diaphragm
as in coughing or sneezing.

Coloptosis may cause these pains by kinking,
in the manner already described. In these cases,
the symptoms are increased on bodily motion or
shaking and are diminished by application of the
proper abdominal support. Deep and glide pal-
pation according to the method of Hamsmann,
as well as the X-ray, will clear up the diagnosis.

Pains in the left hypochondrium may also be
due to diseases of the left kidney, adrenal or tail
of the pancreas as well as to disease of the retro-

322 ABDOMINAL PAIN

denal ulcer may show a location of the pain in the
region of the navel. The pain is to the right of
the navel if the ulcer is in the cap ; otherwise it
may be located to the left.

Such pain may also be due to affection of a
loop of small intestine, especially of a jejunal
ulcer after gastroenterostomy. The latter con-
dition should be suspected in the presence of
heartburn, malena, and hunger pains after opera-
tion. Again, they may be the result of a stenosis
of the upper part of the jejunum by a perijejuni-
tis, a condition which can be diagnosed only by
the X-ray.

In pain located just above the navel, we must
consider the transverse colon as well as the stom-
ach as a possible cause of these pains. The pains
may be colicky and may represent the usual flat-
ulent colic, or they may be symptomatic in in-
flammatory or malignant processes in stenosis
colics. Isolated, nervous, spastic enteralgia is a
rare cause for this pain. The latter condition
may be recognized under the X-ray while watch-
ing the effect of papaverine and belladonna. Such
pains may also be due to adhesions or fixation of
an abnormally* shortened gastrocolic ligament,
a condition resulting from carcinomatous infiltra-
tion. The pains may be cramp-like and inde-
pendent of food intake; there are alternating
constipation and diarrhea, sometimes tenesmus
and general dyspeptic complaints. The rare cases

of pericolitis will be characterized by a horizontal,
tender, cylindrical tumor extending from one
costal arch to the other with gurgling on palpa-
tion and other signs of acute colitis and peri-
colitis.

Periumbilical pains may also be due to disease
of the colon rather distant from the navel, as, for
example, in an abnormally long or distended sig-
moid flexure in volvulus.

Pains somewhat to the right, left, or above the
navel may occur in an attack of cholelithiasis.
Such a location of the pain may result from a
stone in the common duct. Dull pains in the
same region are even more common and are due
to a chronic obstruction in the lower part of the
common duct. Similar pains may also be due to

perforation of the gallbladder by a stone into
the duodenum with a wandering of the calculus
in the small intestines. Acute cholecystitis or
tumor, with or without stone in the gallbladder,
may cause pain in this region if the gallbladder
is enlarged or pulled down by adhesions. Tumor,
gumma, cyst of the liver, or painful liver as in
passive hyperemia, may produce such pains in
the umbilical region, especially if there is an ab-
normally low position of the liver.

Unusual enlargement of the spleen, especially

if associated with perisplenitis, may also cause

ich pains in this region. Affections of the pan-

ias cause pain midway between the navel and

824 ABDOMINAL PAIN

xyphoid, but they may occasionally be located
directly above the navel. These pains may be
due to irritation of the coeliac plexus and may be
the only sign of involvement of the pancreatic
tissue. This may especially occur in carcinoma
or gumma of the pancreas.

Acute pancreatic affections, either hemorrhagic
or necrotic, as well as pancreatic cysts, may lead
to similar intermittent pains above or around the
navel. We find pains in chronic pancreatitis
around the navel appearing about one hour after
meals, remaining two to four hours and ending
with vomiting.

There are two conditions which produce pains
similar to those found in pancreatic disease ; these
are neuralgia of the coeliac plexus and tabetic
crisis. Affection of the coeliac plexus is described
on page 153, etc. The differential diagnosis be-
tween pancreatic disease and tabetic crisis may
be very difficult, as similar pains with intervals
between the attacks occur in each and there may
be a syphilitic history and irregular pupils in
syphilitic disease of the pancreas. Pancreatic
disease may be recognized by the presence of a
tumor in the pancreatic region and by the fact
that the patients have a sensation of discomfort
even during the intervals, while the tabetic is free
from all disturbances during these intervals, ex-
cept, perhaps, for occasional constipation. The
attacks of tabes are of about the same intensity

RENAL, CONDITIONS 325

throughout, while pancreatic disease as carcino-
ma shows marked remissions during an attack.

Renal conditions may cause pains which are
located somewhat to one side of the navel, es-
pecially where the organ is enlarged and situated
low down. Ureteral pain, caused by the passage
of a stone, gravel, or crystals, may also cause
pain in this region. Bilateral pains in these
ureteral cases may be due to a bilateral involve-
ment or they may be caused by a uretero-ureteral
reflex. In these ureteral cases there may be no
skin hyperesthesia or pain on deep pressure over
the lumbar region.

We must think of the possibility of a horse-
shoe kidney either in its usual or pathologically
altered state. The pains in this condition are
sometimes increased on bodily motion or bending
of the body either backwards or forwards. The
patients complain of digestive disturbances whieh
are caused by compression of the intestines. There
may be a palpable tumor in the lumbar region,
and the X-ray examination may be of diagnostic
value.

Affections of the abdominal aorta or its larger
branches, as in sclerosis, syphilis, or aneurism,
may he a cause for such pains in the same manner
that any other retroperitoneal organ or tissue may
he a cause for such pain. All these conditions
cause a sensation of pain located deep in the ab-
domen, almost in the back. The diagnosis of

326

ABDOMINAL PAIN

aortic sclerosis will be made on the tenderness of
this vessel on pressure, the fact that this vessel
runs with a curve to the left instead of straight
down, the presence of a marked and enlarged area
of pulsation which may be seen even in the back,
increased blood pressure in the arteries of the
lower extremities as compared with those of the
upper, cystolic murmur over the aorta without
pressure of the stethoscope, and palpation of the
areas of calcification and deposit when possible.
The pains, especially in the luetic conditions, are
easily produced on the patient's walking or stand-
ing and quickly disappear on his lying down.
Aneurism of the abdominal aorta may cause pain
above the navel region and it may extend towards
the epigastrium. The pains are said to be in-
creased when the patient is on his back or when
he changes his position in bed.

Sudden thrombosis or embolus in the abdominal
aorta may cause very intense, sudden pain which
is usually localized somewhat below the navel and
perhaps radiates towards the lower extremities.
The diagnosis will he made on the presence of
a possible causative disease, and on signs of ar-
terial ischemia in the lower extremities, such as
the appearance of a small pulse or even complete
disappearance of it in the lower extremities, fol-
lowed finally by asphyxia or even gangrene in
the lower limbs, motor and sensory paralysis of
the lower extremities, disappearance of the knee

UMBILICAL PAIN 327

jerk, and appearance of anuria or urinary re-
tension.

Thrombosis of the mesenteric vessels or throm-
bosis of the portal vein with incomplete obliter-
ation of the lumen may cause pains above the
navel and produce intermittent, colicky attacks
if the process is only temporary. Affection of
the portal vein is characterized by the appearance
of signs of portal stasis.

Periumbilical pains may be a* center where
girdle pains concentrate. Spinal nerve disease
may be a cause of such pains.

Changes in the abdominal wall may also pro-
duce pains in this region. Such conditions are
umbilical hernia and diseases of the wall or fatty
tissues in this region as in adiposa dolorosa.

Pain in the Hypogastric Region

The first consideration in cases of either con-
tinuous or intermittent pains in this region in
female patients is disease of the female genitalia.
These diseases may cause motor intestinal dis-
turbances, and we must remember this fact when
such disturbances occur during menstruation. In
view of the above-mentioned close association of
the genitalia with the lower segments of the
bowel, we must also consider genital disease if the
pains from the genitalia are increased during
the bowel movements or intestinal activity in the
lower part of the tract.

I also wish to mention the rather rare occur-
rence of uterine colic in tabes. These colics may
resemble labor pains and may remain for several
minutes.

We must, furthermore, consider inflammatory,
ulcerative, and neoplastic conditions of the blad-
der or foreign bodies or stones in this region.
The ultimate diagnosis will be made on cystos-
copy and examination of the urine. Bladder
pains and tenesmus are also observed in patients
with considerable urinary sediment such as phos-

828

BLADDEK REGION

329

phates, oxalates, or urates. These pains may
radiate to the back, and there may be a burning
pain in the urethra itself. An abnormal urine,
even in the absence of cystitis, may be followed
by pains in the bladder, as, for instance, after the
use of methylene blue or in hematoporphyrinuria.
We find suprapubic pains in the latter group
of cases.

The most severe and continuous pains in the
bladder region occur in severe diphtheritic, gon-
orrheal, tuberculous, or carcinomatous disease of
the bladder. Simple cystitis is followed only by
burning on urination and tenderness over the
bladder. Carcinoma of the bladder may be pri-
mary or, more often, it may be secondary by
extension from the uterus, prostate, sigmoid, or
rectum. Perforation of a rectal or uterine car-
cinoma into the bladder is not rare. In these
cases a careful palpation per rectum or vaginam,
as well as cystoscopy, will help in the diagnosis.

Foreign bodies in the bladder, such as stones,
cause pains which practically completely disap-
pear on the patient's lying down, to appear on
brisk bodily motion. Bleeding from the bladder,
palpation with the sound, the characteristic inter-
ruption on urination, and the cystoscopic and
X-ray findings will all tend to confirm the diag-
nosis in these conditions.

Such pains may also occur in a normal bladder
if it is very much distended by a very large

330 ABDOMINAL PAIN

amount of urine. Rupture of the organ <
a very intense pain in the hypogastric region and
shock. These pains may even extend to the epi-
gastrium or to the region of the heart. We some-
times find a painless interval between the pain
due to the previous distention and that due to
the rupture itself. Such a perforation will be
followed by a diffuse peritonitis if the rupture
is intraperitoneal or by a circumscribed urinary
extravasation if it is extraperitoneal. Acute dis-
tention of the bladder is common in acute con-
gestion of a chronic prostatic hypertrophy. Such
an acute distention may be the first sign of a
prostatic hypertrophy in patients who were ap-
parently in a good state of health.

Similar pains above the symphysis may be due
to an inflammation of the peritoneal covering of
the bladder, pericystitis, or involvement of the
perivesical tissue, called paracystitis, under the
peritoneum. These processes may result from
primary bladder disease caused by stone, stric-
ture, prostatic disease, or affection of other ab-
dominal organs in the vicinity of the bladder. Of
first importance in the latter group is periappen-
dicitis, especially those cases in which the appen-
dix is located on the promontory of the sacrum
or where the appendix hangs down in the pelvis.
Pains and painful tenesmus may be present in
these cases. On rectal and vaginal examination
we often find a marked tenderness in the right

BLADDER REGION

side or posterior part of the pelvis or a doughy
resistance around the rectum.

Acute perisigmoiditis may cause pains at the
symphysis of itself or indirectly through the com-
plicating paracystitis or pericystitis which it pro-
duces. Such pains may also be present in peri-
colitis or in involvement at the hepatic flexure
in coloptosis. Pericystitis may be but a part of
a peritonitis extending to the pelvis.

Pains in the bladder region or tenesmus, pains
during and after urination, and dysuria are often
early symptoms of an acute peritonitis. A per-
forative peritonitis, even from the stomach or
duodenum, may cause tenderness in the bladder
region in the early stages.

Acute pericystitis may also be a part of a pel-
vic peritonitis arising from the female pelvis,
rectum, sigmoid, perirectal tissue, bony pelvis, or
spine. We find pains above the symphysis in
these cases, after diffuse abdominal pains have
already been present over the entire abdomen.
Fever, rectal and vesical tenesmus, and a palpa-
ble exudate mass extending above the symphysis
even as far as the navel may also be present. The
rectum may discharge much mucus as a result of
the venous stasis caused by the compression by
the mass of exudate.

Adhesions about the bladder will be manifested
by pains in this region, sometimes crampy or
simply tearing or bearing down in nature. Pain-

ABDOMINAL PAIN

fill tenesmus may be the only sign of this <
dition. The pains sometimes occur during urina-
tion or distention of the bladder. Both types may
be explained by a tearing or pulling of the ad-
hesions either during the contractions or during
overdistention of the bladder. Adhesions con-
necting the bladder with the rectum or uterus will
cause vesical pain with simultaneous intestinal
colic or dysmenorrhea.

Painful tenesmus with or without radiation in
the pelvis may be purely reflex and is due to a
cramp of the bladder sphincter. The patient may
be able to pass only a few drops of urine, or there
may even be complete retention. Such a reflex
cramp of the bladder sphincter-may be due to dis-
eases of the bladder itself or of the organs in the
vicinity. It may be present in concentrated urine,
in bacteriuria without cystitis, or after the intake
of large quantities of fresh beer or wine.

We must consider the possibility of a throm-
bosis of the venous plexus of the bladder or of
the pelvis in the presence of venous stasis, as in
hepatic cirrhosis. Sclerosis of the abdominal
aorta or its pelvic branches may sometimes cause
severe tenesmus, faintness, weakness, and anxi-
ety. These pains appear during bodily motion
or excitement and disappear when the patient
lies down.

Of still greater importance is the fact that dis-
eases of the upper urinary tract may cause reflex

HYPOQASTBIC PAIN 333

pains in the bladder region. Such bladder man-
ifestations may be an early symptom of a renal
tuberculosis, and we must not forget to look for
the primary source in cases of tuberculous cystitis.

Renal or uretral stone may also cause bladder
pains, and the lower the stone the more severe
will be the attack. The passage of crystals or
gravel may cause pain in this region. Pyelitis,
especially the acute type, in pregnant women
may cause bladder symptoms. The differentia-
tion from acute cystitis is made on the local lum-
borenal findings, a urinary sediment showing
epithelial cells from the renal pelvis, leucocytes,
fat, bacteria, and the results of cytoscopy.

Pains in the hypogastrium, extending upwards
towards the navel or downwards to the groin, is
found in retroperitoneal lymphadenitis or lym-
phangitis arising from some inflammatory process
elsewhere. Moderate edema of the lower extrem-
ities may be present in which the wrong diagnosis
of phlebitis of the iliac vein may be made, though
in the latter condition the pains are located in
the iliac rather than in the hypogastric regions.
Dysuria may also be observed in inguinal hernia.
We must also consider psoas abscess or disease
of the bony pelvis as a cause of bladder symptoms.

Osteomalacia and acute rheumatism of the syn-
chondrosis symphysis must be kept in mind. The
diagnosis will be made on the presence of pain in
the middle of the lower abdomen which is greatly

on pres-
the fact that pains are
TTm«*r mscarai ok afcrapt abduct mil of the
Liw ^ig aaay be jaumi, and the signs
if z^ ^Trnitr^TT ^ct^hereaMd» MLaili» joints may
k ZMr^jnabr miBwmwI W saficylatcs.

C XTK&. a=aKmyriR5§ of the pubic bones and
Tu a^^j j inmr Tiziasiabs awt be mentioned, as well

_ tacks of
Tmr»TTa PaShokgieal changes in the ab-
nnmnuL wilk is ijjrfi a canse for pain in this

We tehj rnnsiier Krrms causes for such pain

T.mxrtz *-i xae awre-named organic

cu fi ck i pains in the
<r a sensation as if a foreign
":orr -5 Tessa: e tie bladder or urethra. The

\ and the pa-
^ccr'frrr onhr of a cutting sensation
»e r*i*5ier sni urethra on urination. Fre-
:t ^rr^iOLx: with painful straining may also
re ces«nai Tbere is a painful trnrgims of the

retention in other cases. Verv
jLre tishtning-like sticking pains in
tbe Kjoier, with radsatkn to the rectum. The
paixcts remain in bed and fed as though the
paiss threw them to the ground when they get
up* These bladder symptoms may come in the
early stages of tabes, in which cases the diagnosis

<*«>.«.

SCIATICA — NEUROSES 335

is difficult. The other signs of tabes will be useful
in the later stages of the disease. General paresis,
luetic meningitis, multiple sclerosis, and diseases
of the cauda equina may also cause such bladder
symptoms. The bladder symptoms may even
temporarily predominate in some of these cases.

Sciatica and polyneuritis may occasionally
cause bladder pains. A condition which was not
formerly recognized as a cause for bladder pains
is disease of the pudenic plexus. There are ten-
derness of the bladder, painful tenesmus, pain on
urination, and, especially, hyperesthesia of the
skin supplied by this plexus. This area resem-
bles a rhomboid on the perineum with one point
on the symphysis and the other at the anus and
laterally along the inner surfaces of the thigh.
The urinary findings are negative.

Neurasthenia, hysteria, and the various neu-
roses may also cause such bladder pains in men
with sexual neurasthenia or old gonorrhea. Fe-
males with asthenic habitus have these symptoms
with burning on urination and painful tenesmus
due to hypersensitiveness of the sympathetic
plexus.

A special type of neurosis is the so-called Irri-
table bladder. It is characterized by frequently
repeated or even continuous tenesmus with radi-
ating pains to the urethra, perineum, anus, or
coccyx. The pains are particularly severe in the
urethra and neck of the bladder. We nearly al-

336 ABDOMINAL PAIN

ways find frequent urination, but it occurs only
during the day. There may be tenderness over
the bladder on both very superficial and deep
pressure. We must always exclude organic dis-
ease such as fissure or erosions of the neck of the
bladder, or similar conditions in the rectum or
anus. Hypogastric pains also occur in men prac-
ticing coitus interruptus, disappearing after the
resumption of normal sexual relations.

The true hysterical, hypogastric pain is charac-
terized by the fact that there is tenderness over
the ovaries on deep pressure where no anatomical
disease really exists. Such pains may be pressing
or burning and may continue for even a month.
They are limited to the bladder or they may ex-
tend farther out laterally. There is exquisite
tenderness when a fold of the skin is lifted. There
may also be anesthesia of the skin over this area.
The usual hysterical symptoms are generally
present in these cases, as well as the inconstancy
of the symptoms and susceptibility to sugges-
tion. It must not be forgotten that a minor ana-
tomical change may cause exaggerated symp-
toms in hysteria.

APPENDIX

In the previous discussion, the subject of pain
was discussed according to its location, but in this
chapter the attempt will be made to discuss
abdominal pain from the point of view of its

I character.
Radiating Abdominal Pain

Distinct radiation of abdominal pain to the
chest, especially in the region of the shoulders,
points to disease of the liver, spleen, stomach,
and duodenum as well as to thoracic disease. It
is also seen in gastric crises, adrenal disease, and
occasionally renal affections. Disease of the pan-
creas, coeliae plexus, and typical cases of gastric
crisis show a radiation of the pain downwards,
even reaching the genitalia or lower extremities.
The radiation alone must not be given decisive
weight, as one may sometimes find a typical radi-
ation in cholelithiasis if it is associated with enter-
optosis. Pancreatic disease and periappendicitis
with infection in the region of the porta hepatis
may occasionally cause pain which radiates up-
ward.

Radiation to the testicle with tenderness of this

668 abdominal pain

organ is characteristic of pain arising in the kid-
neys, its pelvis, or ureter and does not occur in
gallbladder disease unless it is complicated by a
pelvic peritonitis. This radiation may occasion-
ally occur in extrarenal conditions, as in affections
of the sigmoid, hernia, disease of the retroper-
itoneal glands or coeliac plexus, and occasionally
appendicular pains.

Epigastric pains radiating to the left hypocbon-
driuni occur characteristically in gastric ulcer,
but such radiation also occurs in gallstones with
occasional Limitation of the pain to the left hypo-
chondrium and radiation to the heart.

Relation of Abdominal Pain to the Intake
of Food

It may again be emphasized that pain related
with the intake of food need not always be asso-
ciated with a lesion of the gastrointestinal tract.
We find such a correlation in affections of the
liver, gall ducts, pancreas, kidney, and even the
spleen. There need even be no adhesions of these
organs with the gastrointestinal tract.

Fain arising soon or immediately after food
intake need not be associated with disease of the
stomach, as it may also occur in disease of the
appendix, cecum, or sigmoid flexure. This phe-
nomenon may be explained by a reflex activity
of a distant portion of the gastrointestinal tract
upon activity in an upper segment. On the other

PAIN IN DEFECATION 339

pains four to eight hours after meals do
not necessarily point to disease of the lower part
of the gastrointestinal tract, as such a long inter-
val may occur in motor insufficiency of the stom-
ach, in perigastric adhesions, or in gastric con-
tractions after the stomach is already empty. We
also rind such delayed pains in affections of the
duodenum or jejunum, as the pains will not ap-
pear until these segments are well filled.

Abdominal Pain During Defecation

Such pains may occur before, during, or after
defecation and may then gradually disappear.
These pains occur in affections of the anus or
rectum or in lesions which extend up to the sig-
moid flexure. Abscess or peritonitis of the pelvis,
adhesions and tumors of these regions, and dis-
ease of the female genitalia may cause such pains
by extension into the sigmoid or rectum. We
must also remember the tabetic anal crises. Tu-
mors in the vicinity of the coeliac plexus and even
aneurism of the abdominal aorta may cause col-
icky pains before and after defecation.

If a patient complains of pain on defecation,
in which the location of the pain varies, we must
then consider catarrh of the colon with possible
extension to the small intestines. Such cutting
pains may occur in the transverse colon or in the
sigmoid flexure in cases of mucous colitis.

Such pains are also observed in spastic con-

340

ABDOMINAL PAIN

stipation. Ulcerative conditions and carcinoma
of the intestines increase the pain during defeca-
tion as a result of the increased peristalsis. Chron-
ic exudative peritonitis causes abdominal pains
especially before defecation. Pains connected
with defecation are very often due to adhesions,
simple, inflammatory, tuberculous, syphilitic, or
neoplastic in nature. This is not the rule in
chronic appendicitis. We must remember that
disease of any nature or organ may produce
pains during defecation as a result of strain or
contraction of the abdominal muscles during
the act.

All these conditions may be associated with
pains after an enema. Nervous people may com-
plain of nervous tenesmus even after moderate
filling by an enema. Such pains are especially
present in spastic constipation, because the fluid
tends to dilate the spastically contracted loops.
Distention of the cecum may also cause pain after
an enema and may even simulate appendicitis.
An enema may also cause a reflex secretion in
the stomach in cases of gastric or duodenal ulcer
and may cause pain to appear in the usual areas
for these diseases.

Abdominal Pain Associated with Bodily
Motion

We think of peritoneal adhesions, then of arte-
riosclerosis of the abdominal arteries, abdominal

ABDOMINAL PAIN 341

aneurism, angina pectoris, hernia, renal stone,
wandering organs, and occasionally of gastric
ulcer in this type of pain.

Abdominal Pain Associated with a Sensation
of Anxiety

We have to mention intestinal obstruction,
acute pancreatitis or necrosis of this organ, acute
peritonitis, angina pectoris abdominalis, and the
general group of diseases associated with collapse,
such as gallstones or nephrolithiasis.

Abdominal Pain Associated with Obstipation

We are accustomed to associate pain and obsti-
pation with diseases of the gastrointestinal tract.
We also find such symptoms in stone in the biliary
or renal tracts, arteriosclerosis of the abdominal
arteries, and angina pectoris. An attack of the
latter often ends with belching.

Abdominal Pain Associated With
Menstruation

I wish to emphasize the fact that pains or in-
crease in abdominal disturbances which appear
or increase during menstruation are not always
associated with disease of the female genitalia or
with primary or reflex condition. Many anatom-
ical conditions may regularly show symptoms at
the time of menstruation. Such symptoms may
be due to chronic appendicitis, adhesive perisig-

342

ABDOMINAL PAIN

moiditis, nephritis, nephroptosis, pancreas dis-
ease, and sometimes sclerosis of the abdominal
arteries in young people.

In regard to hysteria as a cause of abdominal
pain I wish to say that we should not make this
diagnosis unless all organic causes have been
ruled out, especially when there are hysterical
stigmata and anatomical lesions side by side, as
any organic lesion may in itself be the factor caus-
ing an outbreak of hysterical symptoms.

INDEX

(After the words in parenthesis add the teord "pain"
as the case may be.)

AbderhaWcn reaction, 213
Abderhalden test fur preg-
nancy, 3D
Abdomen, distention of (right
hypochond.), 170
Inter* I parts of, pain in, 260
Abdominal aorta, aortitis of,
124
epigastric region, ecleroais
of, 124
Abdominal pnin, associated with
bodily motion, 340
associated with menstrua-

associated with a senna lion

of anxiety, 341
chronic, continuous, diffuse,

82
during defecation, 339
localized. 83
mild, diffuse, not colicky in

nature, 79
relation of, to the intake of

food, 338
•ever*, diffuse, with shock

and pain, 3
Hist diffuse, with shock,

but without ileus. 45
severe, diffuse, w i t hont

shock, 54
Abdominal radiating pains. .137
Abdominal wall, abscess of

(ileocecal, recurrent). 241
inflnniuirttimi of the skin of

{ileocecal, acute), 240
Abdominal walls, lax (epigas-

tra.1., chron.), ISO

Abscess, liver, pancreas, spleen
(lumbar region, acute,
cont.), 281
renal (lumbar region, acute,

cent), 276
subphrenic (epigastric, not
cramp-tike), 152
Acromegaly (not colicky, mild,

diffuse), 62
Achylia (colicky epigastric) ,

100
Actinomycosis (flanks), 302
and appendicitis or peri-
typhlitis (ileocecal, acute),
223
of appendical tissue ( ileoce-
cal, chron., cont.), 249
Adhesions between spleen and
abdominal walls or stom-
ach (hypochond., left), 3i>0
between stomach and colon

(epigastric region), 128
about the bladder (bypo-
gast.), 331
Addison's disease (epigastric re-
gion), 130
(hypochond., bilateral). 315
(lumbar, chron.), 288
(lumbar, chron., cont.). 294
I shock without ileus), 46
(with shock), 2
Adiposis dolorosa (navel), 327
Adipositas dolorosa (not col-
icky, mild, diffuse), 81
Adrenal apoplexy (without

Adrenal disease

left), 311

(linril.ar rcgior

(hypochond.,

344

INDEX

Adrenal insufficiency (without
shock), 77
tumor of (epigaatral, chron.),
158
Albuminuria orthostatic (lum-
bar, chron., conk), 290
Alcoholics, chronic (epigastric

region), 121
Amysorrhea (colicky epigast),

101
Anal sphincter, paralysis of
(with shock and ileus), 27
Aneurism (epigast., acute), 147
mycotic, rupture of (hypo-
chond., left), 307
of abdominal aorta (epigas-
tric region), 123
of abdominal aorta (lumbar,

chron.), 288
of renal artery (lumbar,
chron., cont), 293
Angina pectoris (epigast.,
acute), 145
(with shock) 2
status angiosus (epigastric,

not cramp-like), 151
subdiaphragmatic (lumbar

region, acute, cont.), 281
subdiaphragmatic (shock
without ileus), 51
Angioneurotic edema (colicky,

epigast.), 115
Anthrax, intestinal ( ileocecal,
acute), 227
of intestine (shock without
ileus), 54

of stomach (epigastric re-
gion), 141
Aorta, abdominal, affections of
(navel), 325
abdominal, sclerosis of (col-
icky epigast.), 109
abdominal, sclerosis of (with-
out shock), 62
thoracic, rupture of (shock
without ileus), 52
Aortic insufficiency (epigast.,

acute), 147
Apoplexy with perirenal tissue
(with shock and ileus), 14
Appendica? epiploic®, torsion of
(colicky epigast.), 89

Appendicitis (epigastric re-
gion), 116

(right hypochond.), 186

(lumbar region, acute, cont),
282

(navel), 318

acute, chronic, adhesive (ileo-
cecal, colicky), 203

and foreign bodies (ileocecal,
recurrent), 246

and maggots (ileocecal, re-
current), 246

chronic (epigastric, not
cramp-like), 149

c h r o n ic ( ileocecal, chron.,
cont), 247

chronic (lumbar, chron.,
cont), 296

high retrocecal (right hypo-
chond.), 187

in children (without shock),
73

in senile persons (ileocecal,
recurrent), 246

mild (colicky, mild, diffuse),
78

without signs of obstruction
(with shock and ileus), 28
Appendix, 337

and circumscribed peritonitis
(with shock and ileus), 27

chronic changes in (ileocecal,
recurrent), 241

adhesions about the (ileoce-
cal, chron., cont), 248

gangrene of (ileocecal, col-
icky), 205

gangrene of (ileocecal, recur-
rent), 243

hematogenous infection of
(colicky epigast), 92

volvulus of (colicky epi-
gast), 89
Arteries, hypoplasia of (col-
icky epigast), 111
Arteriosclerosis (epigastric re-
gion), 121

(without shock), 63
Ascending colon, inflammation

behind the (flanks), 301
Asthma, 160

Atelectasis (hypochond., left),
314

Atrophy, unite yellow ( right
riypocliond. ) , 177
yellow I lumbar, flanks), 274
Author's Preface, vii

Dowel, ulceration of [without
shock), 71

Uradycsirdia (colicky epigast,).

■■ { without shock } ,

RoAedtne'a disease epigastric,

not cramp-like), 195
Ri leducts. colicky pain in
(right, hvpocb., a c u te,
cant.), 102
parasitic, obstruction of
(right hypochond. ) , 175
BilirulmmrU (epigastric re

gion), 121
Blackwntcr fever ( lumbnr re-
gion, acute, cont.). 279
Bladder, conditions of (hypo-
gast), 328
foreign bodies in (hypo-

gast.), 320
irritable (hypogast.) , 335
normal, distended by urine
(hypognst.), 320
sphincter, cramp of (hvpo-
gast.), 332
Blood pressure, increased (epi-
gastric region). 182
Blood transf union (lumhar re-
gion, acute, cont,), 270
BJumbera'a sign, R8
Boas, tender point of (colicky

epigaat.), 95
Bones, dUMM of (flanks, chron.,

cont.), 304
Bones, diseases of (lumbar,
acute, cont.). 28fl
(lumbar, chron.), 2B9
(lumbar, middle line). 304
Bowel affections (lumbar,

chron., cont.). 2S>5
Bowel, contracted loops of
(with shock and ileus), 21
obstruction of (with shock),

2
paresis, localized (with

shock and ileus), 20
stenosis of (without shock),

Caput medusa?, collateral
(with shock and ileus), 32
Carcinoma of pancreas (epi-
gastric region), 123
pyloric (with shock and
ileus), 15
Cardiac hypertrophy (epigas-
tric, not or amp -I ike ) , 151
lanliiijitosis (epigaat., scute),

Cardiovascular disease (epigas-
tric region), 131
Cecum, atony of (ileocecal, re-
current), 243

carcinoma of (ileocecal,
acute), 232

compression of ( ileocecal,
acute), 232

dilatation of ( ileocecal, re-
current) , 244

mobile (ileocecal, recurrent),
243

perforation of (ileocecal,
acute), 234

stenosis of (colicky epigaat.) ,
80

stenosis of (ileocecal, recur-
rent), 245
Cerebrospins I fpver ( ileocecal.

scute), 225
Chlorosis (epigaatral., chron.),

I GO
Cholangitis (right hypochond.),
IBS

acme (right hypochond.) , 170

ulcerative ( right hypo-
chond.), 174
Cholecystitis (epigastrsl.,
chron.), 157

(epigastric region), 118

(flanks). 302

(right hypochond.). 188

purulent, hemorrhagic (ileo-
cecal, colicky). 211

(lumbar, flanks), 272

346

INDEX

Cholecystitis (navel), 323
phlegmonous ( right hypo-
chond. )> 169
(with shock and ileus), 39
Cholelithiasis (epigastric re-
gion), 139
(lumbar, chron., cont.), 294
(lumbar, flanks), 272
(navel), 323

chronic (right hypochond.),
167
Chyluria (lumbar, flanks), 270
parasitic ( lumbar region,
acute, cont.), 280
Cirrhosis, hepatic (hypogast.),
332
hypertrophic (right hypoch.,

diffuse), 199
of liver (epigastric region),
122
Climatic, conditions (colicky

epigast.), 113
Cceliac plexus, irritation of

(navel), 324
Coitus interruptus (hypogast.),

336
Colic, appendicular ( colicky
epigastr.), 87
appendicular (without

shock), 72
from solid organs (with
shock and ileus), 37

gallstone (with shock and
ileus), 36

gastric; hepatic; pancreatic
(epigastric region), 119

hepatic (right hypochond.),
163

genuine intestinal (without
shock), 73

intermittent (iliac, left), 258

intermittent (with shock and
ileus), 5

intestinal obstruction ( left
ileac, acute), 250

of liver or gallbladder (hypo-
chond., left), 312

pseudohepatic (without
shock), 76

renal (with shock), 1
renal (with shock and ileus),
36

simple and stenosis (without
shock), 71

simple intestinal (ileocecal,
colicky), 207

stenosis, of bowel (with
shock and ileus), 37

stenosis, of hollow organs
(with shock and ileus), 37

stercoral (iliac, left), 256
Colicky pains in right hypo-
chondrium, 163

in right ileocecal region, 203

in region of gallbladder, 163

pains, mild, diffuse, 78
Colitis (right hypochond. ), 183

catarrhal (flanks), 299

mucous (epigastric region),
135

mucous (ileocecal, colicky),
206

mucous (without shock), 75

mucous and bronchial
asthma (without shock),
75

plastic, ulcerative (hypo-
chond., left), 310
Colloidal gold test, 115
Colon, adhesions in (ileocecal,
recurrent), 242

anomalies of (ileocecal, re-
current), 244

carcinoma of (hypochond.,
left), 310

colic of (hypochond., bilat-
eral), 215

congeni tally long, 19

disease of (epigastric re-
gion), 134

diseases of (right hypo-
chondrium), 183

diseases of (navel), 317

stenosis in ( hypochond.,
left), 310

spastic conditions of (iliac,
left), 256

stenosis of (ileocecal, recur-
rent), 245

transverse (navel), 322

tumor of (flanks, chron.,
cont), 303
Colonic spasm (epigastric
gion), 136

(flanks), 298

Colonic spasm (hypochond.,

led), 311
Coloptoflis ( hypochond., left) ,

311
Corrosive sublimate poisoning

(shock without ileus), S3
Common duct, stenosis of

(right hypochond.), 171
stone in (right hypochond.),

Congestion of kidney (epigas-
tric region), 117

Constipation, chronic (ileocecal,
colicky), 207
colic (ileocecal, recurrent),
£41

Cystic duct, carcinoma of (right
hypochond.), 171

Cysts, mesenteric (epigastric
region), 131
omental (epigastric region),
131

847

Duodena] ulcer (epigastric re-
gion), 127
(right hypochond.), 182
(navel), 322
anacidity; hyperacidity (epi-

Xstrie region), I2S
mm, carcinoma of (epi-
gastric region), 129
dilatation of ( right hypo-
chond.), 172
hypersecretion of (epigastric

region), 127
ulcer of | epigastric region),
124
Dysentery (ileocecal, acute),

226
Dyspepsia, nervous (colicky

epigaat.), 08
Dyspeptic symptoms (epigas-
tric region). 118
Dyspraxia intermittens angio-
sclerotica i n test i nali a
(without shock), 60
Dystopic organs (localized), 83

Drtjnrdin't point of tenderness,

48
Diabetes ( epigastric region) ,
136
right bypocn., diffuse), IBS
(lumbar, chron., cont.), 204
Diaphragm, ulTrctions of (hy-
pochond., left), 313
contractions of (epigastral.,
chron.), 160
Dlaphragmatitis. acute (hypo-
chond., bilateral), 316
primary (right hypochond.),
182

IHazo reaction, 66

Diseases of reflex origin (epi-
gastral., chron.), 162

Diseases of skin, muscle, con-
nective tisBue (hvpochond.,
left), 314

Distant causes (lumbar, chron.,
cont,). 206

Donaln/.ancfmciner test, 279

Duodena 1 disease ( lumbar,
flanks), 274

Eclampsia (epigastric region),

140
Einphvnema (epigost., acute),

148
Empyema (lumbar region,
acute, cont.), 282
(without shock), 75
Enteralgia, nervous (navel),
317
spastic (navel), 322
Etiterospasm, nervous (without

shock), 7«
Endocarditis (hvpochond..
left). 312
(with shock and ileus), 3D
infectious (hypochond., left),
307
Epigastralgia, 86

and appendicitis ( colicky

epigastr., 86)
colicky. 86

chronic, continuous, 165
obstinate (colicky epigaat.).

Ill
striking (colicky epignit. ) ,

S48

Epigastric pain of abort dura-
tion, not cramp-like, 149

Epiglottis Q, formatioa of
icolicky epigast), HI '

Epileptic mora (without
shock). 75

Erosion, chronic gastric (eol-
ieky epigast*), 96

Eventration \ hvpochoiML, left),
313

Extraduodenal lesions (epigas-
tric region). 128

Extrauterine pregnancy (ileo-
cecal. acute 1 , 213*

Exudate, fibrinous, in perito-
nitis (with &aock and
ileus) , 20

Fatty stools (epigastric re-
gion v, 121

Fecoiiths (without shock), 65

Female genitalia, affections of
(ileocecal, acute). 212
disease of ( hypogastr. ) , 328
pain in (right tivpochond.),
191

Flanks, pain in the. 260, 297
chronic continuous pain in,
303

Flatfoot ( lumbar chron.,
cont.), 297

Flatulence (epigastric, not
cramp-like), 149

Flatus colic (iliac, left), 256

Foramen of TVinafotr, incar-
ceration in (navel), 319

Functional pain (iliac, left),
256

Foreign bodies in bowels (with
shock and ileus), 14

Gallbladder (epigastric re-
gion). 116

(hypochond.. right), 163

adhesions around the (right
hypochond.), 172

carcinoma of (right hypo-
chond.), 171

colicky pains in (right hy-
poch., acute, cont.), 192

Gallbladder disease (oolicky
epigast.), 89

empyema of (epigastraL,
chron.), 157

empyema of (with shock and
ileus), 27

enlarged (right hypochond.),
186

hematogenous infection of
(colicky epigaat.), 92

hydrops of (hypochondrial-
gia dextra), 197

perforation by stone (navel),
323

rupture of (right hypoch.,
acute, cont), 193

Teasels, aneurism of (right
hypochond.), 174
Gallstone colic and renal colic

(right hypochond.), 190
Gallstone "ileus (without

shock), 65
Gallstones (epigastric region),
116

(rigtht hypochond.), 166

(without shock), 65
Gas formation (ileocecal,

acute), 233
Gastralgia and enteralgia (col-
icky epigast), Ill
Gastralgia, arsenic (colicky
epigast.), 112

chlorosis (colicky epigast.),
112

flatulence (colicky epigast.),
HI

Head, skin hyperesthesia
(colicky epigast.), 112

iron (colicky epigast.), 112

galvanic treatment of (col-
icky epigast.), 112

menstrual (colicky epigast.),
93

meteorism (colicky epi-
gast.), Ill

genuine nervous (colicky
epigast.), 92

nervous system (colicky epi-
gast), 112

neurotic (colicky epigast.),
92

secondary and female geni-
talia (colicky epigast.), 93

olicky epi-

rky

Gastric u 1 1

g«t.t, :

(lumhnr, chron.), 287
mid tuberculosis (coli

epigast.),
perforation of (epigast.,
acute, cont.), 142
Gastric ulcerations in tabes

(epigastric region), 12*
Gastritis, atrophic (colicky
epigast), "

EX 349

Heart, dilatation of (epigastric

region). 132
rupture of (shock, without

ileus), G2
Hematoma, traumatic in renal

region I sbock without

ileus), 50
Hematoporphyrinuria ( lumbar

region, acute, cont.). 279
Hematuria (ileocecal, colicky),

210

stenosing (colicky epigaat.),
103
Gastrocolic fistula (epigastric

region), 1

?nt, shortened

Gastrocolic ligarc
(navel), 322

Gastromvxorrhra (colicky epi-
gaat.), 101
(epigastral., chron.). 101

r.nstn.i|>ti-isis (colicky epigast.),
105

Gastrospnsin (colicky epigast.) ,
89, 110

General neuroaia (epigastric
region), 123

Glands, involvement of (flanks,
chron., cont.), 303

Glide palpation, Hatitfrmnnn't
method (hypochond., left).

region).

Glycosuria, (epigaetri

139
Gonorrhea (ileocecal, acute),

228
Gont (epigastric region). 139
Granuloma of Sternberg (ileo-
cecal, acute), 233
Graves' disease (colicky epi-
gast.) , 115
(epigastric region), 140
(ileocecal, scute), 239
(without shock)., 74

Hemoglobinuria ( lumhar re-
gion, acute, eont.), £79
paroxysmal (lumbar, chron,),
2SS

Hemorrhage into degenerated
muscle (not colicky, mild,
diffuse), SI
into the iliopsoas muscle
(with shock and ileus), 38
into perirenal tissues iwith
shock and ileus), 38

Hemorrhagic diathesis (ileoce-
cal, acute), 225

Hemorrhoids, incarceration of
(shock without ileus), 53

Hepatic artery, embolus in
(right hypochond., acute,
cont.), 195

Hepatic disease (lumbar,
flanks), 272

Hepatic flexure (lumbar.cbron.,
cont.), 296

Hepatic rub (colicky epigast.),
91

Hepatic vein, thrombosis of
(right hypoch., acute,
cont.), IBS

Hepatitis, acute parenchyma-
tous (right hypochond. t,
188
non -suppurative, parenchyms.
tons (right hypocb., dif-
fuse), 108

Hernia (epigastric region), 12S
(ileocecal, chron., cont.). 248
diaphragmatic (epigastric re-
gion), 130
diaphragmatic (hypochond.,
left). 313

350

INDEX

Hernia, diaphragmatic (ileoce-
cal, acute), 236
femoral (epigastric region),

129
inguinal (epigastric region),

129
inguinal (flanks), 303
postoperative (epigastric re-
gion), 129
postoperative ( ileocecal, re-
current), 242
Herpes zoster (ileocecal, acute),

238
Hiccough, 160
Hip joint, disease of (ileocecal,

acute), 230
Hippocratic facies, 146
Hirschsprung's disease (ileoce-
cal, recurrent), 247
Horseshoe kidney (navel), 326
Hourglass stomach ( colicky

epigast.), 103
Hunger pain (epigastric re-
gion), 125
Hydrops (epigastral., chron.),

157
Hydronephrosis (lumbar,
flanks), 267
perirenal ( lumbar, flanks) ,
266

rupture of (with shock and

ileus), 14

Hydronephrotic sac, rupture of

(lumbar region, acute, cont.),

278

Hydroureter ( lumbar region,

acute, cont), 277
Hyperemia (epigastric region),
118
of liver (right hypoch., dif-
fuse), 200
passive (epigastric, not

cramp-like), 150
passive (navel), 323
Hyperesthesia, nervous, acid
of stomach (colicky, epi-
gast.), 115
Hypernephroma (right hypo-
chond.), 191
Hypersecretion (colicky epi-
gast.), 98
continuous (colicky epigast.),
99

Hypersecretion, intermittent

(colicky epigast.), 99
Hypertrophy, atenosing, pyloric

colicky epigast.), 103
Hypochondria! pain, bilateral,

316
Hypochondrialgia d extra in
gallbladder region, chronic,
continuous, 197
Hypochondrium, left, pain in
the, 306
right, acute, continuous pain

in, 192
right, diffuse pain over the,

198
right, pain in the, 163
Hypogastric region, pain in, 328
Hypothyroidism (epigastric re-
gion), 123
Hysteria, 160
(hypogast), 335
(lumbar, flanks), 276
(with shock), 2
(without shock), 70
Hysterical fever ( ileocecal,
acute), 237

Icterus (right hypochond., 188

catarrhal ( right hypoch., dif-
fuse), 199

hemolytic (hypochond., left),
308

hemolytic (right hypochond.,
179
Ileocecal region, acute, contin-
uous, pain in, 211

chronic, continuous pain in,
247

left, acute pains in, 249

right, pain m, 203
Ileus (with shock), 2

and albuminuria (with shock
and ileus), 34

and ascites (with shock and
ileus), 32

and obstruction of portal vein
(with shock and ileus), 32

and polyuria (with shock and
ileus), 34

and pylephlebitis of portal
vein (with shock and
ileus), 33

Ileus, due to adhesions from

appendicitis (with shock

and ileus), 2D
due to foreign body (without

shock), 87
paralytic ( with shock and

ileus), 27
perforation (with Bhock and

ileus), 14
Iliac fossa, disease of (flanks),

303

left, recurrent pains in, 256

Impotence, nervous ( lumbar,
flanks), 275

Incarceration (with shock and
ileus), 7
of the small bowel (with
shock and ileus), 10

Indlcanurin ( with shock and
ileus}, 25

Indigestion, acute (colicky epi'
gast.), 03

Indurative pancreatitis (epi-
gastric region), 122

Infarcts, embolic (lumbar,
flanks). 26S

Infectious discuses, (epigastric
region ) , 140
(lumbar region, acute, cont.),
277. 2S6

Infectious, inflammatory condi-
tions {right hypochond.),
171

Influenza, gastrointestinal (epi-
gastric region), 140
gastrointestinal (ileocecal,
acute), 22S

Inguinal gland, suppuration of
(shock without ileus), 53

Insufficiency, aortic (lumbar re-
gion, acute, cont.), 275

Intercostal nerves, affections of
(not colicky), mild diffuse,
82
constriction of (hypochond.,

left), 314
muscles, ribs (hypochond., bi-
lateral), 310

Intestinal colic (flanks) , 208

and intestinal obstruction

(without shock), 70

]n It's! inn! obstruction, acute

{without shock), 04

acute (with shock and ileua),

1, 3
and peritonitis (without
shock), OS
Intestinal paralysis,

(with shock and neusi, ro
Intestinal wall, tumor of
(flanks, cliron., cont.), 303
Intestines, irritation of (with-
out shock), 09
lesions of (epigastric region),

134
stenosis of (colicky epigast.) ,

60
stenosis of (lumbar, chron.),

287
tuberculous ulceration of ( ile-
ocecal, chron., cont.), 248
Introduction, xiii
Intussusception (ileocecal,
acute), 231
and embolism (with shock

and ileua), 30
and thrombosis (with shock

and ileus), 31
in adults (with shock and

ileus), 12
in children (with shock and

ileus). 12
spontaneously heah»d (with

shock and ileus), 13
tumor (without shock), 08
Invagination, chronic ileocecal,
(ileocecal, recurrent), 246
of large bowel (with shock
and ileus), 4
Ischuria (with rbock and
ileus), 18

Jejunal stenosis (epigastric re-
gion). 128
Jejunal ulcer (navel), 322
Jejunum, ulcer of (epigastric
region), 124

852

INDEX

JTermc test, 88

Kidney capsule, fatty, inflam-
mation of (right hypo-
chond.), 101

congenital cystic (lumbar,
flanks), 266

diseases about the (with
shook and ileus), 38

diseases of (lumbar, chron.,
cent.), 290

eehinococcus of (lumbar,
flanks), 268

fibrous adhesions (lumbar,
flanks) , 268

left, disease of (hypoehoiuL,
left). 311

movable ( lumbar, chron^
cont.l, 292

region, apoplexy (shock with-
out ileus) , 49

tumor of (epigastraL,
chron. K 158

tumor of { lumbar, chron.,
tout). 290

tumor of i lumbar, flanks),

tuberculosis of (lumbar,
chron.. eont.t. 291

Kinking of duodenal region
colicky epi*a*0. 104

Kittkt^e of pyloric region (col-
icky cpi^ea^t.*. 104

Xilmm*?* d\*e*s* (lumbar,
m Jkrle t^e*. 304

\ «•»■•«* *tar cell* of. 1*1
b^^rik\*v&o*is i ri^ht hypocftu,
J't»*\ 201
>jLmJsir x chroa... cunt\ 297

1 -!.•»! \ i *»***> ileocecal. «et>

l .■%•*: .vl'c ,'i»;^assr*c r**ton*.

mi iVa; Ovvk'. ^2
t«M%; o"i4. ^Uitt^r. 1n>.ikV..»«

Lead poisoning (lumbar,

flanks), 276

chronic (right hypochond.),
192

chronio (with shock and
ileus), 46
Left lobe of liver, affections of

(hypochond., left), 313
Liver (epigastric region), 116

actinomycosis of (right hy-

poch., acute, cont.), 195

adhesions around the (right

hypochond.), 172

carcinoma of (right hypo-
chond.), 179

colic and chronic affections

(right hypochond.), 174

colic and mechanical obstruc-
tion (right hypochond.),
174

diseases (flanks), 302

eehinococcus cyst of (right
hypochond.), 173

enlargement of (colicky epi-
gwt), 81

enlargement of (right hypo-
chond.), 168

enlargement, abrupt (epigas-
tric region), 133

hyperemia (epigastraL,
chron.), 155

hyperemia, active (epigas-
traL. chron.), 156

inflammation of (epigastraL,
chronic), 156

previous passive hyperemia
of (epigastric region », 133

stasis of bile in (epigastraL,
chronic), 157

suppuration of (right hypo-
chond. i, 178

svphilia of (right hypo-
'chosftLl, 178

vaideriif (right hypo-
chond.). 179

wandering < right hypoelL,
acute, coot.*. 195

Mumcnia (i
scute*. 222
cf weight <
). 237

Lower extremity, infection* of

(ileocecal, acute), 233
Lit ten m sign, 222
Lumbago ( lumbar region,

acute, cant,), 283
Lumbar pain, chronic, continu-
ous, 290
pain, chronic, recurrent, 287
pain in the middle line, 304
region, acute continuous pain

. 275

., 260

region, pains l .
Lumbosacral pie <us (flanks,

ehron., cont.), 304
Lymphadenitis, retroperitoneal

(hypogast.), 333
Lvifiplimi^Uig, retroperitoneal

(hypogast). 333
Lymphatic glands, affections of

(ileocecal, acute), 232
Lymphatic organs, hypertrophy

of (colicky epigait.), Ill
Lymphoma, tuberculous ( ileo-
cecal, i.-!. i ''II., cont.), 240

Malaria ( hypochond., bilat-
eral), 310
(risht hvpm'h., acnt*, cont.),

197

(ileocecal, acute), 222
(lumbar, flanks), 205
chronic ( epigastric region) ,

124
tertian (hypogast.), 334
(colicky epigast.), 97
IfiWlM. ;i iiit ■■ [epijriisti ic re-

gion), 125
Malta fever (hypochond., bilat-
eral). 318

Megasigma congenita (epigas-
tric, not cramp-like), 149

Menstruation (ileocecal, acute),
214
(lumbar, chron.l, 2B0
Mesenteric artery, superior,
embolu s of (ili'iii'rj],
te), 232

Mesenteric artery, superior,
emliolism of (with shock
ami ileus), 31

artery, superior, thrombosis
of (ileocecal, acute), 232

cyst (shock without ileus),
47

cyst (with shock and ileus),
30

cysts (navel region). 320

glands, anthrax (navel re-
gion), 320

glands, disease of (navel),
318

glands, leueemia (navel re-
gion), 320

glands, suppuration of (na-
vel region), 320

glands, syphilis i navel re-
gion), 320

glands, tuberculosis I navel
region), 320

vein, thrombosis of (right
hypochond.), 177

vessels, affection of (navel),
327

vessels and malena (with
shock and ileus), 32

vessels, arteriosclerosis o t
(ileocecal, recurrent), 245

vessels, interruption of circu-
lation of (with shock and
ileus), 29

vessels, obstruction of (left
iliac, acute), 254

vessels, sclerosis of (without
shock), 60

vessels, thrombosis of (with
shock and ileus). 30
Mesoperlarteritis nodosa (with-
out shock), 5S
Meteorism of intestine (with

shock and ileus),
Meteorism of stomach (epigas-
tric region), 118

paralytic. i:t peritonitis
(with shock and ileus), 19
Microga stria (epigastric re-
gion), 130
Migraine, abdominal (right hy-
pochond.), 181

abdominal (epigastric, not
cramp-like), 154

354

INDEX

Miliaria, epidemic (epigastric

region), 141
Mucous membrane, ulceration

of (flanks), 299
Mumps (epigastric region), 141
Myalgia (ileocecal, acute), 240
rheumatic (not colicky, mild,

diffuse), 80
Myocarditis and arteriosclerosis

(epigastric region), 132
infectious (epigast., acute),

146
Myomalacia, acute (hypochond.,

left), 307

Navel, pain in the region of,

317
Necrosis, pancreatic (ileocecal,

acute), 236
Needle-point (colicky epigast.),

97
Nephralgie hematurique (lum-
bar, flanks). 274
Nephritis ( lumbar region,
acute, cont.), 276

acute, hemorrhagic (lumbar,
flanks), 264

chronic ( lumbar, chron.,
cont.), 290

chronic, colicky (lumbar,
flanks), 265

dolorosa (lumbar, flanks),
265

ordinary chronio (lumbar,
flanks), 265
Nervous affections (epigastric,
not cramp-like), 153

causes (hypogast), 334

system ( epigastral., chron. ),
161
Neuralgia, intercostal (right
hypoch., diffuse), 201

lumbar ( lumbar region,
acute, cont.), 285

malarial ( lumbar, flanks ) ,
274

of abdominal nerves (ileoce-
cal, acute), 238

of cflplic plexus (colicky epi-
gast.), 115

of coeliac plexus (epigastric,
not cramp-like), 153

Neuralgia of lumbar plena

(lumbar region, acute,

cont), 285

renal (lumbar, flanks), 274

Neurasthenia (hypogast.), 135

(lumbar, flanks), 274
Neuritis of the vagus (colicky

epigast.), 114
Neuroses during climacterium

(chronic, diffuse), 82
Neurosis, diaphragmatic (hypo-
chond., bilateral), 316
due to carcinoma (right hy-
pochond.), 189
due to gallstone (right hypo-
chond.), 189
sexual in men (colicky epi-
gast), 93
Nicotinism, chronic (colicky
epigast), 110
(without shock), 63
"Nische," 95, 126
'Nonne-Appelt test, 115
Nephrolithiasis ( left iliac,
acute), 150
bilateral (hypochond., bilat-
eral), 316
Nephroptosis of right kidney
(ileocecal, acute), 236
(lumbar, chron., cont.), 292
Nephrosclerosis, malignant
(with shock and ileus), 39

Obstruction, acute intestinal

(with shock and ileus ) , 3, 5

chronic, of large bowel (with

shock and ileus), 12
(hypochond., left), 312

Obturation (with shocK and
ileus), 3

(Esophageal disease (epigastric
region), 119

(Esophagus, disease of (epigas-
tric, not cramp-like), 152
perforation of (epigast,
acute), 145

Oil-test breakfast, 121

Omentitis (ileocecal, recur-
rent), 241

Omentum, torsion of (ileocecal,
acute), 214

Omentum, tumors of (shock
without ileus), 46

Osteomalacia (hypognst.), 333

Osteomyelitis ( ileocecal,
acute), 226

Ovary, torsion of (with shock
and ileus), 34
tumor of (ileocecal, acute),
213

Overstraining in running,
coughing ( hypochond., bi-
lateral!, 316

Oxalate atone (lumbar, flanks).

Pain, diffuse abdominal, with

shock). 1
due to central origin (iliac,

left). 256
due to reflex origin (iliac,

left). 256
Pancreas, affections of (navel),

323
and acute tumor (with shock

and ileus), 41
chronic disease of (without

shock ) , 63
diseases of (right hypo-
chond.), 1R3
oTpcrseeretinn of (epigastric

region). 127
Pancreatic achylia (epigastric

region), 123
affections (epigastric, not

cramp-like), 151
carcinoma (lumbar, ehron.,

cont.), 204
cyst (lumbar, chron., cont.),

294
cysts (with shock and ileus),

44
disease (epigastric region),

119

disease (hypochond.. left) .311

disease and presence of sugar

(with shock and ileus), 44

disease, important signs in

diagnosis (with shock and

ileus), 42
hemorrhage (with shock and

ileus), 39

Pancreatic inflammation (with
shock and ileus), 40

(with shock and
), 39

A icterus (with
shock and ileus), 44
neurosis (with shock and

ileus), 41

atones ( with shock and

ileus), 44

Pancreatitis, acute or subacute

(with shock and ileus), 39

and peritonitis (with shock

and ileuB), 43
and strangulation (with

shock and ileus), 43
( epigastral., chron.), 158
(epigastric region). 117
(right hypoch., acute, cont.),

196
(with shock and ileus), 41
Pandy'a test, 115
Paracystitis (hypogast.), 330
Parkin ton's disease (epigas-

tral., chron.). 180
Parametritis (left iliac, acute),
252
(lumbar region, acute, cont.),
2S3
Paranephritis (lumbar region,
acute, cont), 278. S8B
actinomycotic {lumbar,

chron., cont), 293
acute (with shock and ileus),

38
fibrous (lumbar, flanks), 268
scar-like (lumbar, chron.,
cont), 292
Parasites, intestinal (ileocecal,

acute), 227
Paratyphoid (hypochond., left),
307
(right hypochond.), 169
(ileocecal, acute), 222
Pedicled organs and torsion
(with shock and ileus), 33
Perforation of abdominal or-
gans {with shock and
ileus), 14
of cecum, ileum, stomach
(navel), 319

856

Perforation of stomach or co-
ram (navel), 321
peritonitis (with ahoek and

ileus), 15
peritonitis and intraperito-
neal hemorrhage (with
•hock and ileus), 36
Periappendieal ah see as and
pouch of Dougla** (with
■hock and Ileus) 9 27
Pariappendieitis (epigastric re-
gion), 116
(epigastric, not cramp-like),

149
(right hvpochond.), 186
(ileocecal, chron., cont.), 247
(left iliac, acute), 264
(lumbar region, acute, cont.) ,

282
(lumbar, chron.), 287
(navel), 318

acute (colicky epigast.), 87

acute (ileocecal, acute*), 218

perforated (shock without

ileus), 48

Periarteritis nodosa (epigastric

region), 141

(lumbar region, acute, cont.),

283
(without shock). 68
Pericarditis, acute (epigast.,

acute), 146
Pericholecystitis hypochondrial-
gia dextra, 198
(with shock and ileus), 39
and periappendicitis, 188
Pericolitis (right hypochond.),
183
(navel), 323
exudative (flanks), 299
Pericystitis (hypogast.), 330

acute (ileocecal, acute), 216
Periduodenitis (epigastric re*
gion), 127
acute (right hypoch., acute,
cont.), 196
Perigastritis ( colicky epigast ) ,
107
purulent (epigast., acute),
143
Perihepatitis (epigastrio re-
gion), 133

tissue, apoplexy in (right
hypoch^ acute, east.), lit

tissues, fnftewn—tiom of
(without ahoek), 99
Perisigmoiditis (hypogast.),
331

(left iliac, acute), 253

chronic tuberculous (iliac,
left, discomfort), 268

luetic (iliac left, discom-
fort), 269
Perisplenitis (hynoehondL,lsft),

306
Periureteritis (left iliae,
acute), 261

purulent (ileocecal, acute),
227
Peritoneal adhesions (iliae,

left), 266
Peritoneal adhesions without
shock, 73

cavity, air in (with shock
and ileus), 22

cavity, fluid in (with shock
and ileus), 31
Peritonism (without shock), 66
Peritonitis, acute (hypogast.),
331

acute (not colicky, mild, dif-
fuse), 79

acute (without shock), 66

adhesive (ileocecal, acute),
217
Peritonitis and intraabdominal
hemorrhage (with ahoek
and ileus), 36

and obstruction (with shock
and ileus), 27

and pouch of Dougla** (with-
out shock), 66

carcinomatous (not colicky,
mild, diffuse), 79

chronic, all types (chronic,
diffuse), 82

Peritonitis, chronic, tuliercu-
1'iiiB (without shock), 88

circumscribed ( epigastric, not
crump-like), 151

circumscribed (with shock
and ileus), 26

diffuse, tuberculous ( ileoce-
cal, acute), 219

fibrimvpurul.'nt (without
shock), 09

gangrenous (without shock),
H

in strangulation ileus (with
shock and ileus), £5

miliary tuberculosis of (not
colicky, mild, diffuse), Til

localized I with shock and
ileus), 24

localized, and periappeTi<!ici-
tls; and perisigmr.iiHtis
(not colicky, mild, diffuse),
80

localised, dry (ileocecal,
unite I, 219

of (he pelvis, fibrous (epigas-
tric re K ion). 137

perforative (right hypo-
cbond.), 176

pneumococcic (ileocecal,
acute), 220

pneumococcic (navel), 3111

(irK'umoeiPCcic (not colicky,

mild, diffuse), 79
pneiiniococcio (without

shock), 5S
post! rnumntic (with shock

aad ileus), 28
progressive iibrino-purulent

(localized), 84
purulent (without shock), 65
purulent (with shock and

ileus), lfi
purulent, sweetish, aromatic

odor from mouth I with

shock and ileus), 22
septic (without shock), 58
septic type of (with shock

and ileus), 22
tuberculous I epigastric, not

cramp-like), 151
tuberculous (localized), 84

Peritonitis, tuberculous ( not

colicky, mild, diffuse), 79

tuberculous (without shock),

Perityphlitis, acute ( ileocecal,

acute), 216
Phlebitis, chronic (without
shock), 60
of left iliac vein (left Mine,

acute). 251
of right iliac vein (ileocecal,

acute), 232
retrocolie (flanks), 302
Pick'* polyserositis (right hy-

pochond.), 176
Pleura, diaphragmatic (hypo-

chond.. left), 313
Pleurisy, adhesive (tumhar re-
gion, acute, cont.). 282
chronic (epigastral., chron.),

159
diaphragmatic (eplgast.,

acute), 148
diaphragmatic (shock with-
out ileus), 53
diaphragmatic (lumbar re-
gion, acute, eont,), 281
subdiaphragmatic (hypo-

chond., hihiteral), 310
(ileocecal, acute) , 224
(without shock), 75
Pleuropulmon&ry disease

(shock without ileus), 53
Pneumonia (lumbar region,
acute, cont.), 282
(without shock). 75
basal (right hypochond. 1.182
Pneumoperitonitis (with shock

snd ileus), 18
Pneumothorax (epigast.,
acute). 148
(without shock), 75
chronic (epigastral., chron.),
159
Poisoning by acids; alkalies-.

(shock without ileus), 63
Poliomyelitis, anterior (ileoce-
cal, scute), 23(1
Polycythemia (without shock),

Polyneuritis (hypogast.), 335

•i • *

7 xrst ^m.

.••■.T'i. : ;*T*r*I . 313
?-.•*-■-: : - 7-f-rsrMLT \iy
rt^ -■•■"■■

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105

of livfr rich: hypoclu dif-

fu>o . 200
of spleen or loft kidney (hv-
pochond.. Wt>. 314 "

Pubic bones. a 'Tactions of (hy-
pogast.). 334

Pulmonary tuberculosis (col-
icky cpigast.). 113

Purpura abdominalis (ileocecal,
acute), 232

Pyelitis (lumbar region, acute,
cont.), 277

(hypogast.), 333

(iliac, left), 257
acute (ileocecal, colicky) ,210
acute (lumbar, flanks)! 266
acute (without shock), 59

Pyelonephritis (ileocecal, col-
icky), 210
Pylephlebitis (epigastric- re-

luetic (right faypoehood.),
17t

pvralent (right hypochond.),
170
PvlKhromboaia, acute (with

shock and ileus), 32
Pvloric spasm (colicky epi-

gast). 89
Pviorospasm (colicky epigast),

97.103
Pylorus, displacement of (ileo-
cecal, acute), 235
ulcer near the (right hypo-
ehcnd.), 163
Pylorus, organic stenosis of
i colicky epigast.). 108
carcinoma of (right hypo-
chond.). 182
Pyonephrosis ( ileocecal, acute ) ,

Pyopneumothorax (epigastric,

net cramp-like), 152
Pvtwalpinx (navel), 319

Qvinekr* angioneurotic edema
i ileocecal, acute), 237

Recurrent fever (hypochond.,

bilateral). 316
Recurrent pains in the iliocecal

region. 240
Renal affections (epigastric re-
gion), 136
colics (lumbar, flanks), 260,

274
conditions (lumbar, flanks),

273
conditions (navel), 325
disease (lumbar, middle line),

305
infarcts (with shock and

ileus), 38
stones (lumbar, chron.,

cont), 291
stone (lumbar, flanks), 273

INDEX 359

Renal affections, vessels, vascu-

Sexual organs, heterologous

lar changes in (lumbar,

(colicky epigast. J, HI

.'lirr.Nl, 289

Sigmoiditis (iliac, left, discom-

Renotyplioid (lumbar, Ouki),

fit,. IBS

206

(left iliac, acute), 252

Respiratory disease (epigastric

Small bowel, disease of (epigas-

region), 131

tric region), 134

Retrocolic tissue, in (lam mat ion

Small iiit.slmc, colic of ( ll.v

of (dunks), 300

vel). 317

Retroperitoneal disease (epigas-
tric, not cramp-like), 164

Spermatic cord, tenderness of

(epigastric region), 130

hemitonia (ileocecal, acute).

Spermatorrhea 1 lumbar.

233

Hanks), 275

inflammation (without

Spinal canal, affections of (lum-

shock), 60

bar, middle line), 304

tissue, inflammation of (lum-

Spinal cord (colicky epigast.).

bar region, acute, cont.),

114

280

bleeding in (ileocecal, acute).

Retrocecal periappendicitis and

238

kidney colic (ileocecal, col-

Spinal irritation, neurasthenic

icky), 208

(lumbar, chron., cont.), 297

Retroperitoneal tissue, disease

Spinal nerve disease (navel),

of (hypochond., left). 312

327

Rheumatism, acute, of synchon-

Spine, caries of (ileocecal.

drosis symphysis (hypo-

acute), 239

gast.), 333

diseases ■■< (lumbar, middle

Rhisomely ( lumbar, middle

line), 304

liimtj.tr, abscess of (lumbar

Hinder* lobe, 15T

region, acute, cont.l, 283

Rings, tenderness of (epigastric

lumbar, scoliosis of (without

region), 130

■hock), 60

Rupture of Intestine (ileocecal,

Spleen, enlargement of (navel),

acute), 233

323

rupture of (hypochond., left),

308

torsion of (with shock and

Sarcoma, retroperitoneal (right

ileus), 34

hypochond.), 183

total Hnemic necrosis of (hy-

Scarlatina ( ileocecal, acute ) ,

pochond., left). 308

226

tumor of (epigastral..

Schmidt's fermentation dyspep-

chron.) , 163

sia (navel), 317

wandering, torsion of (hypo-

Hchmidt't test, 121

chond., left), 308

Sciatica (hypogast.), 335
(ileocecal, acute), 238

wandering ( with shock and

(lumbar region, acute, cont.).

Splenic abscess ( hvpochond.,

28S

left), 307

ScnsoMum, clouding of (with

infarct ( hypochond., left ) ,

chock and ileus), 43

307

Seropneumothorax (epigastric,

region, new growths or in-

not cramp-Tike), IS3

flammations in I hypo-

Sexual characteristics undevel-

chond., left). 309

oped (colicky epigast.), 111

tumor (hypochond.. left), 107

360

INDEX

Splenic vein, sclerosis of (hy-
pochond., left), 309
vessels, aneurism of (hy po-
chond., left), 309

Splenomegaly (hypochond.,
left), 307

Status thymicc— lymphaticc—
hypoplastics (colicky epi-
gast.), Ill

Stenosis colic (navel), 317

high rectal (flanks), 298

hypertrophic pyloric (colicky
epigast), 103

intermittent pyloric (colicky
epigast.), 102

mitral ( lumbar region, acute,
cont.), 275

of common duct (colicky epi-
gast.), 91
Stomach, anacidity ( colicky epi-
gast.), 109

and aneurism (colicky epi-
gast.), 108

anorexia (colicky epigast.),
109

arteriosclerosis of (colicky
epigast.), 108

bleeding into the (colicky epi-
gast.), 104

cachexia (colicky epigast.),
109

carcinoma of (colicky epi-
gast.), 100

carcinoma of the posterior
wall of (navel), 321

cough (colicky epigast.), 110

cramp (colicky epigast.), 93

cramps, 85

dilatation of (colicky epi-
gast.), 102

dilatation of (right hypo-
chond.), 172

enlargement of (epigast.,
acute), 143

hematemesis (colicky epi-
gast.), 109

hyperacidity (colicky epi-
gast.), lio

hypersecretion (colicky epi-
gast.), 110

neoplasms of (colicky epi-
gast), 106

Stomach, organic affections of
(colicky epigast.), 93
pains, so-called (epigastric
region), 134

perforation into (epigast,

acute), 143
perforation of (ileocecal,

acute), 234

pneumatosis of (colicky epi-
gast.), 108

polypus of (colicky epigast.),

107
sarcoma of (colicky epigast.) ,

106

scar conditions (colicky epi-
gast.), 106
tumor of (colicky epigast.),

107
vasoconstriction (colicky epi-
gast.), 110
volvulus of (epigast., acute),

144
wall, stretching of, after
meals (hypochond., left),
310
Stone, renal, ureteral (hypo-
gast.), 333
renal (with shock and ileus),
37
Stones in kidney and ureters

(ileocecal, colicky), 208

Strangulation of sigmoid flexure

(with shock and ileus), 8

of small bowel (with shock'

and ileus), 4

Strangury (with shock and

ileus), 18
Subcutaneous tissue seat of
pain (not colicky, mild,
diffuse), 81
Subdiaphragmatic abscess (hy-
pochond., left), 313
Suppuration, subphrenic (lum-
bar region, acute, cont.),
287
Sympathetic nerve (colicky epi-
gast.), 115
Syphilis (ileocecal, acute), 226
hepatic (epigastric, not
cramp-like), 150
Syphilitic lesions (colicky epi-
gast), 96

Table of Contents, xi

Tabes (colicky epigast.), 114
(epignstral., chron.), 1GB
(epigastric region), 123
liver crises of (right hvpo-

cliond.l, 181
(lumbar, Hanks), 274
abdominal ("shock without

ileusl. 50
dorsulis (ileocecal, acute),

gion). 131
Tabetic crisis i navel i. 324

(without shock), 74
Tachvcnrdia (colicky epigast.),

113
paroxysmal (epigast., acute) ,

147
Tenesmus, sigmoid (with shock

and [tail] . 9
Testicle, undescended (ileoce-
cal, acute). 231
undescended, torsion of {with

■hock and ileus), 30
Tetanus. 161

Tetany (ileocecal, acute). 230
and diffuse colic (without

shock ) . Til
Thrombophlebitis of renal ves-

iels (lumbar region, acute,

cent.), 283
Thrombosis, acute portal (right

hypoch.. acute, cont.l, 104
Thymus, hyperplasia of (col-
icky epigast.). Ill
Torsion of pedicled organ (with

shock), 1
Translator's Preface, is
Transverse process, fracture of

(ileocecal, acute), 238
Traube'a sign, 10
Traumatic hernia ( hy perch ond.,

left), 314
Trichinosis (not colicky, mild,

diffuse). 81
dinphragmntic (hvpochond.,

bilateral |, 316
TrouMcau'j

>ex 361

Tuberculosis of appendieal tis-
sue (ileocecal, chron.,
cont,), 249
general miliary (ileocecal,
acute), 219
Tuberculous gland, perforation
of into extriiht'|iittic j/ull
duct (right hypvcli>>n<l. I .
173
ulcer in cecum or appendix
( ileocecal, acute) , 216
Tumor, benign, 233

malignant (ileocecal, acute).

233
movable ( with shock and
ileus), 14
Tympanitic area (epigastric re-
gion). 126
Typhocolitis (ileocecal, recur-
rent), 242
Typhoid (epigastric region) ,
141
( hypoch ond., left), 307
(ileocecal, ncute), 220
(right hypochond.), 183
(right hypoch., diffuse). 202
(shock without ileus), 54
(without shock), 89
Typhoid appendicitis (ileocecal,

acute). 221
Typhoid ulcer of ileum, cecum
or appendix (ileocecal,
acute), £20

duodenal (without shock), A3
gastric (colicky epigast.). 94
gastric (epigastral., chron.),

1GI
tuberculous (colicky epi-
gast.), 96
Ulcus c&llosum penetrans (col-
icky epigast.), 96
Ulcus juxtapyloriewn (epigas-
tric region), 126
Umbilical hernia (navel). 327
Urate stone (lumbar, flanks).

362

INDEX

Ureter, displacement of (lum-
bar, flanks), 271
kinking of (lumbar, flanks),

270
primary disease of (lumbar,

flanks), 269
stenosis, colics of (lumbar,

flanks), 269
torsion of (lumbar, flanks),

270
tuberculosis of (lumbar,

flanks), 269
twisted and oliguria (with
shock and ileus), 34
Ureteral stone (lumbar,

flanks), 260
Ureteritis, fibrinous (lumbar,
flanks), 270
membranacia (lumbar,
flanks), 269
Ureters, inflammation of (ileo-
cecal, acute), 228
Urethra, disease of (lumbar,

flanks), 272
Urinary tract, diseases of (hy-

pogast.), 332
Urinary system (lumbar,

flanks), 260
Urination, painful (with shock

and ileus), 18
Urobilinuria ( epigastric re-
gion), 121
Urogenital diseases ( ileocecal,
colicky), 210
system, tuberculosis of (lum-
bar, flanks), 262
tract, conditions of (epigas-
tric region), 137

Urticaria, intestinal (iliocecal,

acute), 236
Uterine colic in tabes (hypo-

gast.), 3&8
Uterus, carcinoma of (lumbar,

flanks), 271

Vater, papilla of, 127
Volvulus (navel), 323

in sigmoid (iliac, left), 258
of cecum (ileocecal, acute),

230
of cecum and ascending colon

(ileocecal, colicky), 208
(with shock and ileus), 7
of small intestine (with

shock and ileus), 9
of sigmoid flexure (with
shock and ileus), 8
Vomiting, acetonemic (ileoce-
cal, recurrent), 247

Wahl-Schlange'* sign, 6, 16, 24
Wandering kidney (epigastric

region), 137
torsion of (shock without

ileus), 48
Weil's disease (epigastric, not

cramp-like), 160
(epigastric region), 141
Wound pains (colicky epi-

gast), 94

LANE MEDICAL LIBRARY

!
-

OCT is ?e

FEB -8 |J31
JAN 27 I9J

-3 1934
LfcU -1 1931.

JUN * 1954

1,73 Ortner, H, 55563

077b Clinical eymptonifl

v.l tology (Abdonin&l a

1922 ***»" / aAn

-
" *. - tire*
« OCT;;

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